Dedicated to what works in global health programs

GLOBAL HEALTH: SCIENCE AND PRACTICE

2020 Volume 8 Number 2 www.ghspjournal.org EDITORS

Editor-in-Chief Stephen Hodgins, MD, MSc, DrPH, Associate Professor, Global Health, School of Public Health, University of Alberta

Editor-in-Chief Emeritus: James D. Shelton, MD, MPH, Retired Associate Editors Matthew Barnhart, MD, MPH, Senior Science Advisor, USAID, Bureau for Global Health Cara J. Chrisman, PhD, Biomedical Research Advisor, USAID, Bureau for Global Health Elaine Menotti, MPH, Health Development Officer, USAID, Bureau for Global Health Jim Ricca, MD, MPH, Learning and Implementation Science Team Leader, Maternal and Child Survival Program, Jhpiego Madeleine Short Fabic, MHS, Public Health Advisor, USAID, Bureau for Global Health Saad Abdulmumin, MD, PhD, MPH, USAID, Bureau for Global Health Malaria: Michael Macdonald, ScD, Consultant, World Health Organization, Vector Control Unit, Global Malaria Programme Maternal Health: Marge Koblinsky, PhD, Independent Consultant Nutrition: Bruce Cogill, PhD, MS, Consultant Managing Staff Natalie Culbertson, Johns Hopkins Center for Communication Programs Sonia Abraham, MA, Johns Hopkins Center for Communication Programs EDITORIAL BOARD

Zulfiqar Bhutta, The Hospital for Sick Children, Toronto, Aga Emmanuel (Dipo) Otolorin, Jhpiego, Nigeria Khan University, Pakistan James Phillips, Columbia University, USA Kathryn Church, Marie Stopes International, London School Yogesh Rajkotia, ThinkWell, USA of Hygiene and Tropical Medicine, United Kingdom David Sleet, Bizell Group, LLC, Previously Center for Disease Scott Dowell, The Bill and Melinda Gates Foundation, USA Control and Prevention, USA Marelize Görgens, World Bank, USA John Stanback, FHI 360, USA Lennie Kamwendo, White Ribbon Alliance for Safe Lesley Stone, US Department of State/US Agency for Motherhood, Health Service Commission, Malawi International Development, USA Jemilah Mahmood, International Red Cross and Red Crescent Douglas Storey, Johns Hopkins Center for Communication Societies, Malaysia Programs, USA Vinand Nantulya, Busitema University, Uganda

Global Health: Science and Practice (ISSN: 2169-575X) is a no-fee, open-access, peer-reviewed journal published online at www.ghspjournal.org. It is published quarterly by the Johns Hopkins Center for Communication Programs, 111 Market Place, Suite 310, Baltimore, MD 21202. GHSP is made possible by the support of the American People through the United States Agency for International Development (USAID) under the Knowledge SUCCESS (Strengthening Use, Capacity, Collaboration, Exchange, Synthesis, and Sharing) Project. GHSP is editorially independent and does not necessarily represent the views or positions of USAID, the United States Government, or the Johns Hopkins University. For further information, please contact the editors at [email protected]. Global Health: Science and Practice is distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/. Cover caption: COVID-19 has reached almost every corner of the globe. Face masks have become commonplace for essential workers as well as everyday citizens to reduce transmission of COVID-19. © 2020/World Bank Table of Contents June 2020 | Volume 8 | Number 2

EDITORIALS

Will the Higher-Income Country Blueprint for COVID-19 Work in Low- and Lower Middle-Income Countries?

Strategies to radically suppress incidence of COVID-19, as used in higher-income countries, may be unrealistic and counterproductive in most low- and lower middle-income countries. Instead, strategies should be tailored to the setting, balancing expected benefits, potential harms, and feasibility.

Stephen Hodgins, Abdulmumin Saad

Glob Health Sci Pract. 2020;8(2):136–143 https://doi.org/10.9745/GHSP-D-20-00217

Institutionalization of Projects Into Districts in Low- and Middle-Income Countries Needs Stewardship, Autonomy, and Resources

Important attributes for project institutionalization include strong stewardship and champions, affordability, demand for the intervention and perceived benefit, minimal complexity, and optimal intervention design and period of support.

Peter Waiswa

Glob Health Sci Pract. 2020;8(2):144–146 https://doi.org/10.9745/GHSP-D-20-00170

Learning from Community Health Worker Programs, Big and Small

Small, well-implemented, well-evaluated community health worker programs can provide useful insights and inspiration. Testing, learning, and adapting at progressively larger scale can ultimately lead to national-scale programs that achieve sustainable impact.

Stephen Hodgins

Glob Health Sci Pract. 2020;8(2):147–149 https://doi.org/10.9745/GHSP-D-20-00244

COMMENTARIES

Beyond No Blame: Practical Challenges of Conducting Maternal and Perinatal Death Reviews in Eastern Ethiopia

Lack of a professional body to address patients’ complaints regarding quality of health care and absence of clear medicolegal guidance hamper maternal death reviews in Ethiopia.

Abera Kenay Tura, Sagni Girma Fage, Alexander Mohamed Ibrahim, Ahmed Mohamed, Redwan Ahmed, Tadesse Gure, Joost Zwart, Thomas van den Akkerf, on behalf of the AMAN-MAMA investigators

Glob Health Sci Pract. 2020;8(2):150–154 https://doi.org/10.9745/GHSP-D-19-00366

Global Health: Science and Practice 2020 | Volume 8 | Number 2 Table of Contents www.ghspjournal.org

VIEWPOINTS

Coping With COVID-19: Learning From Past Pandemics to Avoid Pitfalls and Panic

It is imperative to concur on the main transmission routes of COVID-19 to explain risk and determine the most effective means to reduce illness and mortality. We must avoid generating irrational fear and maintain a broader perspective in the pandemic response, including assessing the possibility for substantial unintended consequences.

Daniel T. Halperin

Glob Health Sci Pract. 2020;8(2):155–165 https://doi.org/10.9745/GHSP-D-20-00189

Contraception in the Era of COVID-19

As global health systems and communities prepare to meet an unprecedented threat causing increased demands for the care of people with COVID-19, health care providers should strive to ensure continuity of reproductive health care to women and girls in the face of facility service disruption.

Kavita Nanda, Elena Lebetkin, Markus J. Steiner, Irina Yacobson, Laneta J. Dorflinger

Glob Health Sci Pract. 2020;8(2):166–168 https://doi.org/10.9745/GHSP-D-20-00119

Doing Things Differently: What It Would Take to Ensure Continued Access to Contraception During COVID-19

COVID-19 may fundamentally change women’s contraceptive use, meaning that the future we have been planning and procuring for, may not match these changes. In these unprecedented times, we must rethink how we link product and program in the short-term to ensure women’s changing needs are met.

Michelle Weinberger, Brendan Hayes, Julia White, John Skibiak

Glob Health Sci Pract. 2020;8(2):169–175 https://doi.org/10.9745/GHSP-D-20-00171

Multimonth Dispensing of Antiretroviral Therapy Protects the Most Vulnerable From 2 Pandemics at Once

We encourage governments in countries that have a high prevalence of people living with HIV to implement multimonth dispensing of antiretroviral therapy to safeguard both patients with HIV and health care workers from COVID-19.

Ariana Moriah Traub, Temitayo Ifafore-Calfee, Benjamin Ryan Phelps

Glob Health Sci Pract. 2020;8(2):176–177 https://doi.org/10.9745/GHSP-D-20-00160

Global Health: Science and Practice 2020 | Volume 8 | Number 2 Table of Contents www.ghspjournal.org

Ebola: A Hyperinflated Emergency

As with the Ebola outbreak, global under-5 mortality and morbidity should be considered a public health emergency of international concern.

Victor K. Barbiero

Glob Health Sci Pract. 2020;8(2):178–182 https://doi.org/10.9745/GHSP-D-19-00422

Breaking Specialty Silos: Improving Global Child Health Through Essential Surgical Care

Children’s health care providers and children’s surgery providers can partner to improve children’s health by developing the surgical workforce, focusing on “best buy” surgeries, integrating children’s surgery into national plans, streamlining data collection and research, and leveraging financing.

Isaac Wasserman, Alexander W. Peters, Lina Roa, Farhana Amanullah, Lubna Samad

Glob Health Sci Pract. 2020;8(2):183–189 https://doi.org/10.9745/GHSP-D-20-00009

ORIGINAL ARTICLES

District Health Teams’ Readiness to Institutionalize Integrated Community Case Management in the Uganda Local Health Systems: A Repeated Qualitative Study

District health teams failed to transition from partner-supported integrated community case management (iCCM) programs to locally-run and fully-institutionalized programs. Successful iCCM institutionalization requires local ownership with increased coordination among governmental and nongovernmental actors at the national and district levels.

Agnes Nanyonjo, Edmound Kertho, James Tibenderana, Karin Källander

Glob Health Sci Pract. 2020;8(2):190–204 https://doi.org/10.9745/GHSP-D-19-00318

Scaling Up Access to Implants: A Summative Evaluation of the Implants Access Program

The Implants Access Program increased access to implants by addressing price, supply chain, service delivery, and knowledge and awareness barriers. Sustaining progress requires institutionalized mechanisms to continue global efforts and long-term assurances that implants’ low price will be maintained.

Rebecca Braun, Annika Grever

Glob Health Sci Pract. 2020;8(2):205–219 https://doi.org/10.9745/GHSP-D-19-00383

Global Health: Science and Practice 2020 | Volume 8 | Number 2 Table of Contents www.ghspjournal.org

What Goes In Must Come Out: A Mixed-Method Study of Access to Contraceptive Implant Removal Services in Ghana

Many Ghanaian women seeking implant removal are able to obtain services, but knowledge and access gaps exist.

Rebecca Callahan, Elena Lebetkin, Claire Brennan, Emmanuel Kuffour, Angela Boateng, Samuel Tagoe, Anne Coolen, Mario Chen, Patrick Aboagye, Aurélie Brunie

Glob Health Sci Pract. 2020;8(2):220–238 https://doi.org/10.9745/GHSP-D-20-00013

Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal

Data from a retrospective costing analysis offers insights and practical considerations for policy makers and locally elected officials for designing and implementing a new community health work cadre as a mechanism to achieve SDG targets in Nepal.

Prajwol Nepal, Ryan Schwarz, David Citrin, Aradhana Thapa, Bibhav Acharya, Yubraj Acharya, Anu Aryal, Aaron Baum, Ved Bhandari, Laxman Bhatt, Dipak Bhattarai, Nandini Choudhury, Binod Dangal, Meghnath Dhimal, Santosh Kumar Dhungana, Bikash Gauchan, Scott Halliday, SP Kalaunee, Lal Bahadur Kunwar, Duncan Maru, Isha Nirola, Rashmi Paudel, Anant Raut, Hari Jung Rayamazi, Sabitri Sapkota, Dan Schwarz, Poshan Thapa, Pratistha Thapa, Aparna Tiwari, Roshani Tuitui, Eric Walter, Sheela Maru

Glob Health Sci Pract. 2020;8(2):239–255 https://doi.org/10.9745/GHSP-D-19-00393

Implementing the Clean Clinic Approach Improves Water, Sanitation, and Hygiene Quality in Health Facilities in the Western Highlands of Guatemala

A water, sanitation, and hygiene (WASH) intervention implemented in a short period in health care facilities with limited resources achieved improvements in health care facility infection prevention readiness.

Jason Lopez, Sergio Tumax Sierra, Ana María Rodas Cardona, Stephen Sara

Glob Health Sci Pract. 2020;8(2):256–269 https://doi.org/10.9745/GHSP-D-19-00413

Evaluating the Implementation of an Intervention to Improve Postpartum Contraception in Tanzania: A Qualitative Study of Provider and Client Perspectives

Training and supervision to improve interpersonal aspects of care, including an emphasis on patient-centered counseling, informed choice, and respectful and nondiscriminatory service delivery, should be integrated into future postpartum family planning initiatives.

Kristy Hackett, Sarah Huber-Krum, Joel M. Francis, Leigh Senderowicz, Erin Pearson, Hellen Siril, Nzovu Ulenga, Iqbal Shah

Glob Health Sci Pract. 2020;8(2):270–289 https://doi.org/10.9745/GHSP-D-19-00365

Global Health: Science and Practice 2020 | Volume 8 | Number 2 Table of Contents www.ghspjournal.org

FIELD ACTION REPORTS

Recall Efforts Successfully Increase Follow-Up for Cervical Cancer Screening Among Women With Human Papillomavirus in Honduras

A reminder phone call had a substantial impact on high rates of women returning for rescreening among those at high risk of developing cervical precancer. Scaling up routine cervical screening coverage must be accompanied by efforts to retain women throughout the screening cascade and continuum of care.

Kerry A. Thomson, Manuel Sandoval, Carolyn Bain, Francesca Holme, Pooja Bansil, Jacqueline Figueroa, Silvia de Sanjosé

Glob Health Sci Pract. 2020;8(2):290–299 https://doi.org/10.9745/GHSP-D-19-00404

REVIEW/META-ANALYSIS

Close to Home: Evidence on the Impact of Community-Based Girl Groups

Available evidence, though limited, shows that programs can use community-based girl groups to help adolescent girls improve attitudes toward gender roles and norms, early pregnancy, and child marriage; evaluations indicate they have suboptimal performance on health behavior and health status.

Miriam Temin, Craig J. Heck

Glob Health Sci Pract. 2020;8(2):300–324 https://doi.org/10.9745/GHSP-D-20-00015

Global Health: Science and Practice 2020 | Volume 8 | Number 2 EDITORIAL

Will the Higher-Income Country Blueprint for COVID-19 Work in Low- and Lower Middle-Income Countries?

Stephen Hodgins,a Abdulmumin Saadb

Key Message Policy makers and public health officials around the world are struggling to optimize their response across Strategies currently pursued in high-income and multiple dimensions of complexity: to maximize benefit upper middle-income countries—aimed at radically and minimize collateral harm. One common denomina- suppressing incidence of COVID-19—may be un- tor across settings is the virus itself. So, some of the trans- realistic and counterproductive in most low- and mission dynamics, for example, the virus’ incubation lower middle-income countries. Instead, strategies period, are fairly stable and predictable across all need to be tailored to the setting, balancing settings—both high-income and upper middle-income expected benefits, potential harms, and feasibility. countries (referred to in this article as higher- income countries [HICs]) and low- and lower middle- income countries (collectively referred to in this article as LMICs). But many other parameters that are relevant BACKGROUND to finding the best solutions vary considerably across set- he Spanish Flu pandemic of 1918–1919 waxed and tings, so we need different strategies for different settings. Twaned over 2 years, evolving in the process, eventu- ally reaching every corner of the planet and striking down an estimated 50–100 million people.1 Dispro- THE HIC BLUEPRINT portionately, it killed young adults. There was no vac- Phase 1: Suppression cine and no effective treatment. In many cases, the viral Although the details and relative emphasis across elements illness killed through secondary bacterial pneumonia. At of the strategy have varied somewhat, nearly all HICs have that time, antibiotics to treat these secondary infections did not exist. responded to the COVID-19 epidemic using essentially the A century later, we are dealing with a different virus same paradigm, albeit with varying degrees of effectiveness. that attacks in a somewhat different way. Severe acute They began with an aggressive suppression phase, aiming to respiratory syndrome coronavirus 2 (SARS-CoV-2)— rapidly reduce the effective reproductive number (Rt)* to less the virus that causes coronavirus disease (COVID-19)— than 1. The popular media has described this more often us- “ ” infects the lungs directly and also causes death by ing the less technical expression, flattening the curve. The inducing a state of “cytokine storm,” disturbing coagula- key strategic goals of this phase have been to avoid over- tion, and attacking other organs. Disproportionately, it whelming hospitals and to buy time, which has entailed kills the very old. The new virus appears to be similarly ramping up capacity for resource-intensive critical care (no- infectious2 and similarly lethal3 to the Spanish Flu. tably ventilators and intensive care unit beds) to treat severe However, these are still early days and there’s much we cases, and to conduct testing, tracing, isolating of identified do not know, including how it may affect different popu- cases and quarantining their close contacts to control spread. lations in different geographies and what long-term se- Achieving rapid reduction of Rt to <1 has required very quelae may result. substantial reduction in social contact, attained in most Modelers from Imperial College London and elsewhere instances through shelter-in-place and lockdown policies. have warned that, unimpeded, SARS-CoV-2 could kill mil- Across all HICs, it has been recognized that it was critical to lions over the next 1–2 years.4 Although it is appropriate get in place robust provisions for test-trace-isolate. that we focus very seriously on impeding progress of the There has been some variation by country and region. pandemic, at the same time, we need to give equally seri- Generally, in East Asia, there was a rapid initial response ous attention to ensuring the least terrible collateral out- with aggressive provisions for test-trace-isolate (including comes.Andthatwillbetricky. institutional isolation and quarantine of cases and close con- tacts). As a result of rapid and generally pretty effective ac- a Editor-in-Chief, Global Health: Science and Practice Journal, and Associate tion, the cumulative incidence in these countries, to date, Professor, School of Public Health, University of Alberta, Edmonton, Alberta, Canada. b *The basic reproductive number, R0, is the average number of new incident cases Global Health Support Initiative-III, United States Agency for International arising from each infection in the absence of any control measures. The effective Development, Washington, DC, USA. reproductive number, Rt, which we focus on in this article, varies over time Correspondence to Stephen Hodgins ([email protected]). depending on control measures.

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has been comparatively low. In countries in Europe or post-conflict states fall into this LMIC economic and North America, in general, the initial response category. The differences in resources, age structure, was slower (Germany being a notable exception). stability, and state capability are relevant to deter- There has been less appetite for out-of-home, institu- mining likely benefits, harms, and feasibility associ- tional quarantine; instead, most jurisdictions in these regions have used a strategy of population-wide ated with possible responses to COVID-19. The lockdown.5 challenge for decision makers is to choose feasible, During the suppression phase in some HICs, contextually-appropriate strategies, balancing ex- certain socioeconomic arrangements, such as pected benefits versus harms and seeking to achieve meat-processing plants in North America and mi- the least terrible population outcomes. grant worker dormitories in Singapore and the In relation to efforts to control COVID-19 in Gulf states, have created super-spreading condi- LMICs, let’s consider 3 questions: tions where special efforts have subsequently been needed to bring transmission under control. 1. What is the expected benefit? In a number of HICs, the elderly living in nursing homes and assisted-living facilities have been at 2. What harms could arise? very high risk and have accounted for a large pro- 3. How feasible is the “flattening the curve” portion of deaths.** Thus, these settings, too, have mantra? more recently been given focused attention to en- sure a higher level of protection from exposure. The original strategy had to be adapted based on facts 1. What is the Expected Benefit? on the ground. Age Structure As we have noted, unlike the Spanish Flu, which Phase 2: Maintenance disproportionately ended the lives of young adults, Beyond the initial suppression phase, HICs are now COVID-19 is disproportionately killing the elderly beginning to transition to a maintenance phase. The and those with certain underlying morbidities; goal in this second phase is to keep Rt<1 (i.e., keep therefore, its impact varies by population structure. the daily count of incident cases on a downward Around the world, there are marked differences be- trend), through continued, but less restrictive, tween populations. In Canada, 17% of the popula- physical distancing (more commonly described as tion is aged ≥65 years; many European countries “ ” social distancing ) and provision for rigorous test- have more than 20% of the population aged trace-isolate action, quickly identifying cases and ≥65 years and Japan has 28% aged ≥65 years. By outbreaks, and rapidly moving to contain them. The contrast, most countries across South Asia and decision about how early to relax lockdown and be- sub-Saharan Africa have between 3% and 4.5% in gin moderating physical distancing is complicated this age group (i.e., about 7-fold less as a proportion and involves tradeoffs. of the whole population). All else being equal, keeping the suppression phase in place for longer before transitioning to Although COVID-19 is certainly causing some maintenance phase means reducing the levels of deaths among younger adults and mortality risk ongoing transmission considerably lower. But increasesforthoseintheir60sandintotheir70s, this level of transmission can only be achieved at risk is especially high for the very old. In Canada, those high cost due to the disruptions caused by pro- aged 80 years or older account for only 4% of the longed stringent lockdowns. Mitigating collateral population but for 70% of COVID-19 deaths.5 harms during the suppression phase has been UsingtheagestructuresofCanada6 and Nigeria7 in enormously costly, but because these countries 8— have deep pockets, more or less adequate provi- 2018 and age-specific case fatality all else being — ’ sions for social insurance have been feasible (at equal if 70% of both countries populations were least for now). infected, the expected number of deaths/100,000 in Canada would be 1,358; in Nigeria, 265—5-fold BUT WILL THE HIC BLUEPRINT WORK fewer. So, the expected mortality impact of the epi- demic, unhindered, is considerably lower in most IN LMICS? LMICs than in HICs†; therefore, the benefit of strin- LMICs differ from HICs not just in terms of available gent control measures like sustained lockdowns is resources but also in having substantially younger much less in LMICs than in HICs. age distributions. Most fragile and conflict-affected † Clearly, factors other than age can contribute to risk of severe disease. **Indeed, in some HICs, like Canada, preemptive efforts to decongest Nutritional factors and co-existence of certain other infections may in- acute care hospitals to accommodate an expected surge of COVID-19 crease risk in LMICs. Furthermore, for those experiencing more severe cases resulted in more dangerous super-spreading conditions in many COVID-19 infections, case fatality is likely to be higher in the absence of of the long-term care facilities into which these patients were transferred quality critical care services. It may certainly turn out to be the case in and, ultimately, in higher numbers of COVID-19 deaths than would many LMICs that case fatality is higher in younger age groups than what otherwise have occurred. has been seen in East Asia, Europe, and North America.

Global Health: Science and Practice 2020 | Volume 8 | Number 2 137 Context-Appropriate Approaches to COVID-19 for Low- and Middle-Income Countries www.ghspjournal.org

But There Doesn’t Seem to Be Much COVID-19 Yet has also been problematic). At this level of testing, in LMICs we don’t know what’s really happening with What should we make of the apparently low spread of the virus. number of cases, to date, in South Asia and sub- Saharan Africa? In part, we may be seeing the 2. What Harms Could Arise? lull before the storm. Compared to Europe and Counterproductive Effects on COVID-19 Spread North America, early in 2020, there was consid- In most LMICs, strict lockdowns—particularly if erably less seeding of cases imported into most efforts are made to sustain them beyond a few LMICs from other countries. Many LMICs im- — posed lockdowns, restricted flights, and closed weeks are likely to cause considerable harm. borders comparatively early in the epidemic. In Indeed, even for the avowed purpose of reducing some LMICs (e.g., island states, parts of sub- spread, some control measures have been counter- Saharan Africa), initial spread may be impeded productive. For example, in some countries, lock- by less dense transportation linkages. And in downs have resulted in chaotic, high-volume 14 some societies, because of the structure of social out-migration from cities, as informal-sector work- networks, spread may be slower (this may, for ers try to return to their home villages, carrying the example, be the case in rural West Africa).9 virus with them. Similarly, hundreds of thousands of A large proportion of cases may have minimal migrant workers have recently been obliged to return symptoms (due to age structure, and probably due to their countries of origin—notably in South Asia— to less obesity); more severe cases are either not seeding new outbreaks on their return. getting to hospital or, if hospitalized, not recog- nized as cases of COVID-19. This would give an Impact on the Economy and Food Systems iceberg-like scenario, with most disease activity In almost all LMICs, the majority of the working- below the water line. age population is employed in the informal sector. It has been speculated that temperature or Compared to HICs, most LMICs have weaker ca- other climate-related effects may mitigate the pacity and much fewer resources to draw on to COVID-19 impact in the tropics, although evi- provide adequate social insurance measures to 10 ’ dence available to date doesn t provide strong support those whose employment is interrupted support for this hypothesis. Note that the due to control efforts. With overly aggressive con- Spanish Flu had especially crushing impact in trol measures, half a billion people risk being South Asia, which may have suffered a quarter pushed into absolute poverty.15 of all deaths (as many as 25 million, according to 1 Disruptions to food systems that impair food Barry ). Even if seasonality turns out to be a char- production and distribution (e.g., through border acteristic of COVID-19 (as it is for the commonly shutdowns and suspension of trade in sub- circulating coronaviruses), there is likely to be a Saharan Africa, where many countries depend on muddier, more complicated seasonal picture in imports for a large proportion of their food) risk the tropics (as there is for influenza). There has creating mass hunger, possibly compounded in also been speculation, based on work done on some regions by locust infestations or drought. “innate immunity” and correlations at the coun- try level, that prior exposure to BCG could confer some protection against COVID-19, resulting in Lack of Access to Education less transmission in countries that have widely Education of children is a key concern in all socie- used this vaccine.11 This may give us some reason ties, but even more so for countries with young to hope; however, the available ecologically- populations, recognizing that education is a vitally grounded evidence is weak.12 important determinant of future life opportunity. Butmostimportant,todatetherehasbeenfar Online education is not an option for the over- less testing than in most HICs, so—to the degree whelming majority of families in LMICs. Sustained COVID-19 is already spreading—it has been largely disruption of schooling will have serious long-term invisible (indeed in some countries it appears it has consequences, especially for the poor. Furthermore, been deliberately kept invisible). Based on the most given that severe COVID-19 illness is rare in chil- recent reported data13 available at the time this ar- dren, that they appear to be less susceptible, and ticle was written all LMICs have been testing fewer available evidence that child-to-adult transmission than 1 person/10,000 population per day; some has played a very small role in propagating the epi- (Nigeria, notably) have been testing fewer than 1/ demic,16 the epidemiologic rationale for keeping 100,000 (in some settings, the quality of testing schools closed is weak.

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Disruption of Routine Clinical Services 20% increase in malaria deaths (mainly among In HICs, there has been a major focus on trying to children age <5 years in Africa), an excess of ensure adequate critical care beds for the expected 80,000 over the coming year.20 burden of severe COVID-19 cases. However, most From their modeling work using the Lives LMICs cannot realistically expect to provide such Saved Tool, investigators from Johns Hopkins care for all who could benefit from it (though Bloomberg School of Public Health21 estimate they certainly need to be making efforts to provide that if there are significant enough disruptions some degree of care for such cases, to the extent to maternal, newborn, and child health pro- ‡ possible ). Disrupting services and discouraging grams at the primary health care level in LMICs people from seeking care in hospitals can be to reduce coverage for key interventions by expected to reduce timeliness of treatment for po- 40%–50%, there would be an excess of tentially life-threatening conditions like appendi- 1,157,000 child deaths and 56,700 maternal citis and myocardial infarction. Indeed, in some deaths over the next 6 months (i.e., almost 4 times LMICs, there have been anecdotal reports of pri- as many as deaths directly caused by COVID-19 vate hospitals refusing to admit any patients with worldwide over the 6-month period from when the fever or other symptoms suspicious for COVID- epidemic began through mid-May (318,000 deaths 19. In addition to discouraging timely recourse at time of writing). Is a death due to COVID-19 neces- to hospital services for acute medical problems, sarily a bigger tragedy than the death of a 3-year-old heavy control efforts risk undermining phar- maceutical supply chains and impairing access that would not otherwise have occurred (or 4 such to drugs needed by those with significant excess deaths, for that matter)? chronic medical problems like diabetes and hypertension. Burden of Vaccine-Preventable Diseases From 1988 to 2010, due to effective efforts in LMICs Reductions in Use of Primary Health Care to ensure that all pregnant women are vaccinated Based on their modeling, investigators from against tetanus, the number of deaths per year due Imperial College London17 estimate that COVID- to neonatal tetanus decreased by 93%, from an esti- 22,23 related disruption to tuberculosis and HIV services mated 787,000 to 58,000. Significant reductions could result in a 10% increase in HIV mortality, in tetanus immunization of pregnant women due to mostly as a consequence of interruptions in antire- interruptions in use of routine antenatal services troviral treatment.14 With current annual HIV would result in a corresponding rise in newborn tet- mortality estimated at 770,000,18 that translates to anus deaths. 77,000 excess deaths over the coming 12 months. Polio has been on the point of eradication. The Imperial College investigators estimate that With suspension of control efforts, there is every disruption to tuberculosis services could result in a reason to believe it will silently spread, setting 20% increase in deaths, mostly due to reductions in back eradication efforts by years. In Afghanistan, timely diagnosis and treatment of new cases. With Nigeria, and Pakistan, polio vaccination cam- 1.5 million19 people currently dying from tubercu- paigns have stopped. losis per year, that would mean 300,000 excess Measles is an extremely contagious disease deaths over the coming year. which, in addition to killing through direct infec- Routine clinical preventive services may not tion, results in the infected child having reduced seem glamorous, but when they are allowed to immunity for months after the initial infection lapse due to suspending outreach services or ab- (analogous to AIDS) with a large proportion of sence from post by health workers afraid of con- deaths due to secondary infections. In poor coun- tracting the infection, this will quickly result in tries, measles kills 3%–6% of those it infects increases in otherwise easily preventable deaths. (mostly infants). With major gains in measles im- Significant disruptions to malaria services (nota- munization coverage, measles was, for a time, bly distribution of insecticide-treated nets and eliminated from the Western hemisphere, but access to treatment services) could result in a now it’s back. In 2018, there were 140,000 deaths attributable to measles.24 As recently as 2000, there ‡ Even if intensive care unit beds and ventilators are not available, other were close to 1 million measles-associated deaths elements of care can be provided to improve survival and reduce mor- bidity among severe, hospitalized cases. Efforts to make oxygen much worldwide among young children (60% in sub- more widely available in secondary-level health facilities (health centers, Saharan Africa and 30% in South Asia). In the district hospitals) would certainly be helpful. And certainly, as in HICs, efforts need to be made to improve infection prevention procedures and pre-immunization era, there were far more practices and to ensure health worker safety. measles deaths. With an extended disruption of

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immunization services, there will certainly be ma- with comparatively weak state capability or dis- jor measles outbreaks in LMICs. There is certainly trust between the State and the population, or reason to fear hundreds of thousands of additional sensitivities about interfering with religious ac- measles deaths over the next 1–2 years. The greater tivities, how feasible will it be to maintain such the disruption to routine immunization activities, proscriptions? the greater the number of such deaths. In settings where people depend on informal With this many lives at risk, how much disrup- (sometimes crowded) markets to procure their tion can we afford? food on a daily or near-daily basis, how feasible will it be to close them down? “ ” 3. How Feasible is the Flattening the Curve How long can hard lockdowns be sustained in Mantra? settings where most people work in the infor- We have already noted much younger popula- mal sector? tions in LMICs than in HICs. There are also marked differences in household structure and as- How likely is it over the short- to medium- sociated degree of social contact by age category.4 term, in most LMICs, that there will be ade- In LMICs, social contact rates are similar across age quate capacity for robust, widespread testing, groups and the majority of the elderly live in multi- contact tracing, and effective isolation of identi- generational households, typically numbering 5 or fied cases and their close contacts? more people. By contrast, in most HICs, average On the positive side, many societies in LMICs social contact rates decline considerably from have very robust social systems that represent mid-adulthood on and most of those aged 65 years an important resource to be drawn on in re- or older live either alone or as couples (although sponse to COVID-19, although they are cur- a significant proportion of the very elderly, aged rently quite constrained by hard lockdowns. 80þ years, live in nursing homes and assisted- living facilities). This has consequences for social It is certainly possible that Sub-Saharan Africa mixing and the opportunity for spread to these and South Asia may represent less fertile ground ’ high-risk older people. for the virus. At this point, we really don t know. Related to number of household members, But, with all of these challenges, how realistic is it there is also the issue of floor-space per person. to think that Rt can be reduced to and maintained This varies directly with per-capita income, with at less than 1 in most LMICs? Even some HICs are much less space per person, on average, in LMICs currently struggling to achieve reductions in new than in HICs. Tighter quarters means enhanced op- cases (evident in some Latin American countries portunity for transmission. Of course, this is true at the time this article was written). not only within households but also within com- munities. Housing density varies markedly by set- IF THE HIC BLUEPRINT ISN’T A GOOD ting. At the extreme end of the spectrum are major FIT, WHAT WOULD MAKE MORE slums in LMICs; a good example is Dharavi, a slum in Mumbai numbering 1.2 million living in an area SENSE? 2 2 Yes, everyone is preoccupied with risk associated of 2.4 km (500,000 people/km ). In such settings, 25 we have multiple factors compounding the likelihood with the infection, but Jones has challenged us “ of spread: within-household crowding, within- also to take into account the risk of exaggerated ” neighborhood crowding, many homes lacking direct fears and misplaced priorities. Decision makers piped water, a large proportion of the working-age in LMICs need to make strategic choices prioritiz- population engaged in the informal sector, and gen- ing across multiple domains, taking into account erally weak state capability and governance. demographics and resources available, and con- sidering: what’s feasible, what’s acceptable, and ’ Consider the following: what s the expected net benefit/harm of the choices being considered. As we have been argu- Self-isolation has been promoted in HICs for ing, the 2-phase approach pursued in HICs with those with either new respiratory symptoms or re- the goal of initial rapid suppression—pushing Rt cent contact with a possible case. At population- to less than 1— and then moving into a mainte- wide scale in most LMICs, how feasible is this like- nance phase, keeping incidence low, is unlikely ly to be? to be feasible in most LMICs. Instead, LMICs will In all countries, efforts have been made to sus- need to find ways of coping with a continued rise pend planned mass gatherings. In countries in incidence and minimizing overall negative

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impact. Certainly, other important issues will Instituting as robust provisions for test-trace- need attention (notably, management of severe isolate are feasible, strategically targeting avail- cases). In most if not all LMICs, 3 key objectives able testing capacity, quarantining confirmed will likely be appropriate: cases and their close contacts, and identifying and controlling outbreaks. In principle, there is 1. Limit spread, short of full suppression potential for big impact on spread if this is done 2. Mitigate harms associated with control efforts widely and well (and this is much less disrup- 3. Shield those at high risk (and avert deaths) tive than population-wide lockdowns).

Let’s consider each of these, in turn. 2. Mitigate Harms As we have noted in the earlier discussion, with 1. Limit Spread more extreme control efforts there is every reason If it’s accepted that with the efforts that can feasi- to believe there will be more severe consequences bly be deployed on a sustained basis (i.e., for many (already evident in many places). With a high pro- months) it will not be possible in most LMICs to portion of the population working in the informal push Rt to less than 1 and keep it there, the num- sector, generally quite limited scope for social in- ber of new cases will continue to increase. This surance support for those unable to work, and means continued spread until the virus runs out high risks for widespread impoverishment, miti- of susceptible hosts to jump to and further spread gating such harms requires less aggressive disrup- spontaneously fades off—the level popularly de- tion of the economy. Food systems need to remain scribed as “herd immunity.” functional. Health care, including routine clinical Accepting continued growth in new cases does preventive services, needs to be maintained with not mean efforts should not be made to slow the in- minimal disruption, through more targeted, less draconian approaches to physical distancing. crease. Even if an Rt of less than 1 cannot be achieved and maintained, a slower increase means As in HICs, attention in LMICS also needs to be a smaller volume of severe cases at any given time directed toward mitigating potentially serious psy- chosocial consequences including anxiety or and fewer infected over the long term. Key ele- depression, stigma, sociopolitical unrest, and vio- ments of a strategy to slow spread should include: lence that may arise from people’s response to the Recommending locally-appropriate, sustainable epidemic and associated control efforts. In part, forms of physical distancing, including: encour- mitigating such consequences can be achieved aging universal mask use when in prolonged through sound, strategic communication to health close contact in tight, enclosed spaces, for exam- workers and the general population26: having a ple on buses and trains (as well as masks and trusted, authoritative source of information; dis- other personal protective gear for health work- seminating accurate, useful information; preemp- ers); installing barriers made of plexiglass or sim- tively addressing fear and anxiety, myths, and ilar material to protect workers in close contact misinformation; and encouraging support for the with customers or co-workers; shifting activities vulnerable. There needs to be honesty about the outdoors where feasible; encouraging and sup- facts: many will be infected, and this won’tbe porting appropriate respiratory etiquette (cover- over soon. ing coughs/sneezes; into inside of elbow, not hand) and hand hygiene (improving access to wa- 3. Shield Those at High Risk ter, to the extent feasible); practicing self-isolation Those most at risk are the elderly.§ In LMICs, most for those who have new respiratory symptoms. of the elderly live in multigeneration households, Eliminating or at least reducing super-spreading not on their own or in institutions (as is more circumstances using feasible, locally-appropriate, common in HICs). Protecting the shielded will re- quire reducing the networks of possible transmis- solutions including seeking to suspend mass sion into the home and to the elderly members of gatherings and decongest crowded conditions in the household, by mobilizing members of the prisons, slums, barracks, migrant-worker dormito- household and others as shielders, who will need ries, markets, and workplaces. In all informal ur- ban settlements, there need to be emergency § Certainly the same principle of shielding applies also for those with planning committees formed to work out effec- important underlying conditions like chronic heart or lung conditions, poorly controlled diabetes, obesity, or compromised immunity, who are tive, feasible, and acceptable solutions. also at elevated risk of severe infection.

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to adopt more rigorous physical distancing prac- 5. Government of Canada. Coronavirus disease (COVID-19): outbreak tices.27 In crowded living conditions, this will be update. Updated May 22, 2020. Accessed May 18, 2020. https:// www.canada.ca/en/public-health/services/diseases/2019-novel- difficult. Effective strategies need to be developed coronavirus-infection.html?topic=tilelink locally. 6. Statistics Canada. Annual demographic estimates: Canada, The best protection would, of course, be an ef- provinces, territories, 2018. Ottawa: Statistics Canada; 2019. fective vaccine. It may well be that effective (and Accessed May 19, 2020. https://www150.statcan.gc.ca/n1/pub/ affordable) treatments will be identified over the 91-215-x/2018002/sec2-eng.htm coming year and beyond, in which case, their use 7. Nigeria: age structure from 2008 to 2018. New York, NY: Statista; 2020. Accessed May 19, 2020. https://www.statista.com/ can also form an important part of the response. statistics/382296/age-structure-in-nigeria/ As we wait for that moment, world leaders need 8. Verity R, Okell LC, Dorigatti I, et al. Estimates of the severity of coro- to commit that when such a vaccine is first avail- navirus disease 2019: a model-based analysis. Lancet Infect Dis. able, priority for its distribution will be based on 2020;S1473–3099(2)30243-7. CrossRef. Medline need (notably the elderly and those with relevant 9. Awoonor-Williams JK, Phillips JF, Kachur SP, Jackson EF, Moresky “ chronic conditions) not wealth.28 RT, Chirawurah D. Response to How prepared is Africa to face COVID-19? by Wadoum and Clarke. Pan Afr Med J. Forthcoming 2020. SOME FINAL WORDS 10. Martinez-Alvarez M, Jarde A, Usuf E, et al. COVID-19 pandemic in – We are certainly not the first to note the problem west Africa. Lancet Glob Health. 2020;8(5):e631 e632. CrossRef. Medline of uncritical mimicry of HIC solutions in response 29,30 11. Miller A, Reandelar MJ, Fasciglione K, Roumenova V, Li Y, Otazu GH. to the COVID-19 epidemic or to suggest that Correlation between universal BCG vaccination policy and reduced 28,31,32 different strategies are needed in LMICs. morbidity and mortality for COVID-19: an epidemiological study. But the needed new strategies are not yet much medRxiv. Preprint. Posted online March 28, 2020. CrossRef in evidence. We call on national governments 12. Faust L, Huddart S, MacLean E, Svadzian A. Universal BCG vacci- and the international agencies and donors seeking nation and protection against COVID-19: critique of an ecological study. Journal Club: Coronaviruses: past, present and future. to support them to undertake the tough challenge Published April 1, 2020. Accessed May 22, 2020. https:// of crafting context-appropriate strategies that ap- naturemicrobiologycommunity.nature.com/users/36050-emily- propriately balance expected benefits, potential maclean/posts/64892-universal-bcg-vaccination-and-protection- against-covid-19-critique-of-an-ecological-study harms, and feasibility. Such strategies are likely to ’ 13. Daily COVID-19 tests per thousand, rolling 3-day average. Our look quite different from what we ve seen, to date, World In Data website. Accessed May 22, 2020. https:// in HICs. As frightening as this virus itself may ourworldindata.org/grapher/daily-covid-19-tests-per-thousand- seem, if it commands all of our attention to the ex- rolling-3-day-average clusion of broader considerations, misplaced pri- 14. Biswas S. Coronavirus: India’s pandemic lockdown turns into a hu- orities could result in greater harm. man tragedy. BBC News. March 30, 2020. Accessed May 19, 2020. https://www.bbc.com/news/world-asia-india-52086274 15. Sumner A, Hoy C, Ortiz-Juarez E (2020). WIDER Working Paper Acknowledgments: We would like to express our appreciation to the 2020/43: Estimates of the impact of COVID-19 on global poverty. following people for feedback provided on earlier drafts of this paper; UNU-WIDER, Helsinki. Accessed May 20, 2020. https://www. their input helped strengthen the article. They include: Matt Barnhart, Jim Shelton, Victor Barbiero, James Phillips, John Koku Awoonor-Williams, wider.unu.edu/sites/default/files/Publications/Working-paper/ Daniel Halperin, Richard Cash, Sudhir Khanal, Deepak Paudel, Ellen PDF/wp2020-43.pdf Pierce, Kedar Baral, Eric Sarriot. 16. Zhu Y, Bloxham CJ, Hulme KD, et al. Children are unlikely to have been the primary source of household SARS-CoV-2 infections. Disclaimer: The views expressed in this article are solely the views of the medRxiv. Preprint. Posted online March 30, 2020. CrossRef authors and do not necessarily reflect the views of the United States 17. Hogan AB, Jewell B, Sherrard-Smith E, et al. Report 19: The Potential Agency for International Development or the United States Government. Impact of the COVID-19 Epidemic on HIV, TB and Malaria in Low- and Middle-Income Countries. London: United Kingdom: Imperial REFERENCES College London; 2020. Accessed May 22, 2020. https://www. imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/ 1. Barry JM. The Great Influenza: The Story of the Deadliest Plague in report-19-hiv-tb-malaria/ History. London, United Kingdom: Penguin Books; 2004. 18. UNAIDS. Global HIV & AIDS statistics—2019 fact sheet. UNAIDS 2. Vynnycky E, Trindall A, Mangtani P. Estimates of the reproduction website. Accessed May 19, 2020. https://www.unaids.org/en/ numbers of Spanish influenza using morbidity data. Int J Epi. resources/fact-sheet 2007;36:881–889. CrossRef. Medline 19. Tuberculosis. World Health Organization website. Published March 3. Taubenberger JF, Morens DM. 1918 Influenza: the mother of all 24, 2020. Accessed May 19, 2020. https://www.who.int/news- pandemics. Emerg Infect Dis. 2006;12(1):15–22. CrossRef. Medline room/fact-sheets/detail/tuberculosis. 4. Walker PGT, Whittaker C, Watson O, et al. Report 12: The Global 20. World Health Organization (WHO). The Potential Impact of Health Impact of COVID-19 and Strategies for Mitigation and Suppression. Service Disruptions on the Burden of Malaria: a Modelling Analysis London, United Kingdom: Imperial College COVID-19 Response for Countries in sub-Saharan Africa. Geneva: WHO; 2020. Team; 2020. Accessed May 22, 2020. https://www.imperial.ac. Accessed May 22, 2020. https://www.who.int/publications-detail/ uk/mrc-global-infectious-disease-analysis/covid-19/report-12- the-potential-impact-of-health-service-disruptions-on-the-burden-of- global-impact-covid-19/ malaria

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21. Roberton T, Carter ED, Chou VB, et al. Early estimates of the indirect communication-and-community-engagement-%28rcce%29-action- effects of the COVID-19 pandemic on maternal and child mortality in plan-guidance low-income and middle-income countries: a modelling study. Lancet 27. van Bunnik B, Morgan A, Bessell PR, et al. Segmentation and shield- Glob Health. May 12, 2020. CrossRef. Medline ing of the most vulnerable members of the population as elements of 22. World Health Organization (WHO). Maternal and Neonatal an exit strategy from COVID-19 lockdown. medRxiv. Preprint. Posted Tetanus (MNT) elimination. WHO website. https://www.who.int/ online May 8, 2020. CrossRef immunization/diseases/MNTE_initiative/en/. Updated March 5, 28. Cash R, Patel V. The art of medicine: has COVID-19 subverted global 2020. Accessed May 19, 2020. health? Lancet. May 5, 2020. CrossRef 23. Liu L, Johnson HL, Cousens S, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 29. Oestericher D. When lockdown becomes a death sentence: the co- with time trends since 2000. Lancet. 2012;379(9832):2151–2161. ronavirus response in the developing world. The Politic. May 9, CrossRef. Medline 2020. Accessed May 22, 2020. https://thepolitic.org/when- lockdown-becomes-a-death-sentence-the-coronavirus-response-in- 24. World Health Organization (WHO) and Centers for Disease Control the-developing-world/ and Prevention. More than 140,000 die from measles as cases surge worldwide. WHO website. https://www.who.int/news-room/ 30. Piper K. The devastating consequences of coronavirus lockdowns in detail/05-12-2019-more-than-140-000-die-from-measles-as- poor countries. The Vox. April 18, 2020. Accessed May 22, 2020. cases-surge-worldwide. Published May 12, 2020. Accessed May https://www.vox.com/future-perfect/2020/4/18/21212688/ 19, 2020. coronavirus-lockdowns-developing-world 25. Jones DS. History in a crisis—lessons for COVID-19. N Engl J Med. 31. van Zandvoort K, Jarvis CI, Pearson CAB, et al. Response strategies 2020;382(18):1681–1683. CrossRef. Medline for COVID-19 epidemics in African settings: a mathematical model- ling study. medRxiv. Preprint. Posted online May 3, 2020. CrossRef 26. World Health Organization (WHO). Risk Communication and Community Engagement (RCCE) Action Plan Guidance: COVID-19 32. Mehtar S, Preiser W, Lakhe NA, et al. Limiting the spread of COVID- Preparedness & Response. Geneva: WHO. Accessed May 19, 19 in Africa: one size mitigation strategies do not fit all countries. 2020. https://www.who.int/publications-detail/risk- Lancet. April 28, 2020. CrossRef

Cite this article as: Hodgins S, Saad A. Will the higher-income country blueprint for COVID-19 work in low- and lower middle-income countries? Glob Health Sci Pract. 2020;8(2):136-143. https://doi.org/10.9745/GHSP-D-20-00217

© Hodgins and Saad. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-20-00217

Global Health: Science and Practice 2020 | Volume 8 | Number 2 143 EDITORIAL

Institutionalization of Projects Into Districts in Low- and Middle-Income Countries Needs Stewardship, Autonomy, and Resources

Peter Waiswaa,b

. See related article by Nanyonjo et al. estimated that, despite marked progress, 74,000 children die every year in Uganda—the majority from preventable Key Messages diseases.2 One of the main strategies that has the potential to make significant improvements to child health in sub- n There are too many projects in developing Saharan Africa is a strong district-led integrated commu- countries; ill health continues because most 3 projects fail to be institutionalized. nity case management (iCCM) implementation. n Although a district-led integrated community case management project in Uganda had donor sup- INSTITUTIONALIZATION OF A DISTRICT- port, sufficient implementation led by a non- LED PROJECT IN UGANDA governmental organization, and adequate human 4 resources, it had no national or district budget for The article by Nanyonjo et al. in this issue of GHSP commodities and lacked supervision and mon- reports the findings of an evaluation of their efforts to in- itoring. All these are characteristics of a failed stitutionalize iCCM in 9 districts of Western Uganda. design for institutionalization. Designed by the United Nations Children’s Fund and n Institutionalization requires optimal design with the World Health Organization, iCCM is a strategy that stewardship, autonomy, capacity, affordability, relies on community health workers (CHWs) using sim- minimal complexity, and a system for ple algorithms to offer health promotion, disease preven- accountability. tion, and curative services for uncomplicated diarrhea, malaria, and pneumonia. Since 2010, iCCM has been pol- icy in Uganda, and it evolved from the Home-Based riven by high morbidity and mortality, weak health Management of Fever program and policy. Working in Dsystems, weak governance, and poverty, many close collaboration with the Ministry of Health (MOH) in countries in sub-Saharan Africa have a multitude of pro- Western Uganda, the Malaria Consortium used a health jects led by government, nongovernmental organiza- systems strengthening approach to introduce and try to tions, and researchers trying to fill gaps. Unfortunately, institutionalize iCCM in the districts from 2010 to 2015. although the rhetoric is usually to “institutionalize” the They took institutionalization to mean that a health inter- project, many of these projects often fail in what others vention becomes a routinely practiced and integral part of call “pilotitis”1 —a situation in which projects are first the conventional health system—I would like to add piloted but not sustained or scaled up. This is a practice “without much more effort from external actors.” Their that many governments claim that they are tired of, but creative evaluation used qualitative research methods in business as usual still continues. 2010 to assess for “district preparedness” for institutional- In this way, Uganda is no exception. As a result, de- ization and later in 2015 to assess the outcomes of their spite proliferation of “high-impact” projects, child mor- efforts. A major limitation of their approach to evaluation tality remains high in Uganda, and the country is is that it (1) does not include any quantitative measures of unlikely to achieve the Sustainable Development Goals “readiness” or “institutionalization,” so it is difficult to related to child health. A recent United Nations report measure the change; and (2) does not describe in detail any institutionalization activities or findings between 2010 and 2015. a Maternal, Newborn, and Child Health Centre of Excellence, Makerere University School of Public Health, Kampala, Uganda. Based on my decade-long work in districts and our b Department of Global Public Health, Karolinska Institutet, Solna, Sweden. experiences with project implementation at the Makerere Correspondence to Peter Waiswa ([email protected]). University Maternal NewbornandChildHealthCentreof

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Excellence (MNCH Centre)5 in Uganda, the results medicines to community members with fears of of their evaluation were not surprising: failed insti- wastage, affordability, and development of anti- tutionalization. After 5 years of support, the districts microbial resistance. In addition, the iCCM design were not able to maintain supply of medicines, su- has additional flaws: scale-up of iCCM requires pervision and motivation of CHWs, or mainte- thousands of CHWs, who receive and manage nance of the reporting system. The authors medicines, treat people, and report regularly. In attributed the poor institutionalization to lack of essence, each of these iCCM CHWs is a “health stewardship on how to transition from externally center.” Indeed, even the MOH considers them supported implementation to district-led program- so, and they are called “health center level 1” as ming, conflicting guidelines on community distri- Nanyonjo et al. also report. These CHWs who bution of medicines, poor community-level have medicines are in addition to the thousands accountability systems, and limited decision- of other health centers that are located, on aver- making autonomy at the district level. age, within 5 km of households. It is clear that What really drives institutionalization? Similar such a complex program, although desirable, is to the Malaria Consortium, our MNCH Centre not affordable or indeed sustainable, especially so implemented the District Empowerment for Scale- by districts. up (CODES), an iCCM project in 16 high-burden districts in Uganda. CODES was designed to diag- ATTRIBUTES FOR SUCCESSFUL nose and resolve health system bottlenecks, pri- INSTITUTIONALIZATION marily the challenges related to the district’s management of local health services. We found From the above, in addition to what we saw in the that although CODES improved uptake of child Maternal and Newborn Scale-Up project, here, we health interventions, the CODES approach was learn about other important attributes for institu- difficult to sustain (forthcoming publication). tionalization, namely: affordability, minimal com- However, similar to the findings that Nanyonjo et plexity, and optimal intervention design. The al. report, we found that the main barriers included World Health Organization and others recom- limited fiscal space constraining district managers’ mend that if projects are to be institutionalized or ability to implement solutions identified through sustained, they need to be “designed with the end CODES.6–9 In another project, the Maternal and in mind.” Among several presumably successful Newborn Scale-Up project, in Eastern Uganda, we projects that failed institutionalization in Uganda aimed to improve newborn care in 6 hospitals is the Saving Mothers, Giving Life project. serving 4 million people over a 5-year period. All Although the project reportedly reduced maternal 6 neonatal care units we started are still functional mortality rate by 40%, it was never sustained be- 2 years after implementation ended.10 We consider cause it had minimal design involvement by the this to be a true institutionalization. Factors that MOH, was costly, and was too complex for district facilitated institutionalization included: (1) strong health systems to absorb after the departure of leadership involvement and engagement; (2) the external financing and nongovernmental organiza- emergence of champions, (3) alignment to policy tion management.11 Examples of successful pro- and structures, (4) use of mainly local resources, jects that have been institutionalized in Uganda such as hospital space, no additional health include immunization and the supply of critical workers, commodity availability from the hospi- antimalarial drugs and family planning commodi- tal’s own resources, and routine data systems; ties in health facilities. (5) health workers’ and community’sdemandand To conclude, for Uganda’s iCCM project to be perceived benefit; and (6) implementation over a institutionalized, it must be redesigned. Such a de- fairly long time (5 years) with full local staff and sign must include strong leadership at the center leaders’ involvement. and in the districts, more use and alignment to Unfortunately, this was not the case with the existing structures and resources (nearby health Malaria Consortium iCCM project. They report centers with their staff) except in hard-to-reach that they did not find the MOH engagement ade- areas, additional resources at the MOH and in quate. Further, the CHWs (called village health districts, more district-level decision space, and teams in Uganda) are an informal voluntary struc- marked accountability and involvement of com- ture and are not salaried and depend on cash and munity and district-level actors. In real terms, it other incentives. Finally, they report that there means nongovernmental organizations should se- was no government/district budget for medicines cede their power and resources to the districts or supervision, and there was a concern of giving right from the beginning and there should be a

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mechanism for ensuring capacity and accountabil- empowerment intervention: early implementation experiences from ity from the districts and the central government. Uganda. BMC Public Health. 2015;15:797. CrossRef. Medline 7. Waiswa P, O’Connell T, Bagenda D, et al. Community and District REFERENCES Empowerment for Scale-up (CODES): a complex district-level man- agement intervention to improve child survival in Uganda: 1. Huang F, Blaschke S, Lucas H. Beyond pilotitis: taking digital health study protocol for a randomized controlled trial. Trials 2016; interventions to the national level in China and Uganda. Global 17(1):135. CrossRef. Medline Health. 2017;13(1):49. CrossRef. Medline 8. Henriksson DK, Ayebare F, Waiswa P, Peterson SS, Tumushabe EK, 2. Alkema L, Chou D, Hogan D, et al. Global, regional, and national Fredriksson M. Enablers and barriers to evidence based planning in levels and trends in maternal mortality between 1990 and 2015, the district health system in Uganda; perceptions of district health with scenario-based projections to 2030: a systematic analysis by the managers. BMC Health Serv Res. 2017;17(1):103. CrossRef. UN Maternal Mortality Estimation Inter-Agency Group. Lancet. Medline 2016; 387(10017):462–474. CrossRef. Medline 9. Henriksson DK, Peterson SS, Waiswa P, Fredriksson M. Decision- 3. Young M, Wolfheim C, Marsh DR, Hammamy D. World Health making in district health planning in Uganda: does use of district- ’ Organization/United Nations Children s Fund joint statement on in- specific evidence matter? Health Res Policy Syst. 2019;17(1):57. tegrated community case management: an equity-focused strategy to CrossRef. Medline improve access to essential treatment services for children. Am J Trop 10. Makerere University Centre of Excellence for Maternal, Newborn Med Hyg. 87(5 Suppl):6–10. CrossRef. Medline and Child Health (MNCH Centre). Regionalisation of Health Care: 4. Nanyonjo A, Kertho E, Tibenderana J, Källander K. District health Experiences and Lessons From the Maternal and Newborn Scale up ’ teams readiness to institutionalize integrated community case man- (MANeSCALE) Project in Eastern Uganda. Kampala: MNCH Centre; agement in the Uganda local health systems: a repeated qualitative 2019. Accessed April 29, 2020. https://www.healthynewborn study. Glob Health Sci Pract. 2020;8(2). CrossRef network.org/resource/regionalization-of-health-care-experiences- 5. Namudiba KP. A Rights-Based Analysis of the Impact of Patriarchal and-lessons-from-the-maternal-and-newborn-scale-up-manescale- Norms on Women’s Reproductive Autonomy in Uganda [disserta- project-in-eastern-uganda/ tion]. Pretoria, South Africa: University of Pretoria; 2019. 11. Conlon CM, Serbanescu F, Marum L, et al. Saving mothers, giving 6. Katahoire AR, Henriksson DK, Ssegujja E, et al. Improving child sur- life: it takes a system to save a mother (Republication). Glob Health vival through a district management strengthening and community Sci Pract. 2019;7(1):20–40. CrossRef. Medline

Received: April 29, 2019; Accepted: April 29, 2020

Cite this article as: Waiswa P. Institutionalization of projects into districts in low- and middle-income countries needs stewardship, autonomy, and resources. Glob Health Sci Pract. 2020;8(2):144-146. https://doi.org/10.9745/GHSP-D-20-00170

© Waiswa. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/ 10.9745/GHSP-D-20-00170

Global Health: Science and Practice 2020 | Volume 8 | Number 2 146 EDITORIAL

Learning from Community Health Worker Programs, Big and Small

Stephen Hodginsa

Key Message Most of the documentation and learning published in the peer-reviewed literature on CHW programs has n Small, well-implemented, well-evaluated commu- been based on comparatively small programs, often nity health worker programs can provide useful implementing narrow sets of interventions, over a rela- insights and inspiration. tively short period of time by local or international non- governmental organizations or by university-based n Testing, learning, and adapting at progressively groups, in most instances with external funding.2 As a larger scale can ultimately lead to national-scale consequence of the filter of the peer-review process, programs that achieve sustainable impact. much of this analytic work has been done with high levels of internal validity, but often at the cost of wider pro- grammatic relevance (i.e., external validity). At the same See related article by Nepal et al. time, at least some of these documented experiences have also been important inspirations for global and national- level policy makers and program developers. urrently, there is widespread enthusiasm for com- A case in point is work done by Abhay and Rani — Cmunity health worker (CHW) programs. There is a Bang in a comparatively poorly-served, rural popula- commonly held view that these programs can make im- tion in eastern Maharashtra, India, consisting mostly of aadhivasi “ ”— portant contributions to improving population-level or scheduled tribes demonstrating that health outcomes, not only in areas of community-based well-designed and well-supported CHW programs can — substantially reduce child and newborn mortality, even primary health care (CBPHC) like maternal-child 3,4 health, family planning, nutrition, HIV, tuberculosis, in challenging contexts. This work served as an impor- and malaria—but also in emerging high-burden health tant impetus for work worldwide, beginning about conditions, such as hypertension and other noncommu- 20 years ago, seeking to drive down newborn mortality nicable diseases.1 using community-based strategies (e.g., under the But the global health community has gone through Saving Newborn Lives projects funded by the Bill and repeated waves of enthusiasm and disappointment with Melinda Gates Foundation and a series of global projects CHW programs in the past. The potential of such funded by the United States Agency for International programs—demonstrated in exemplary pilot projects— Development). In this issue of GHSP, we have a helpful new contri- has often failed to translate into impactful, institutional- 5 ized programs, operating at scale. bution by Nepal et al., looking closely at costing of an Learning not only from CHW programs but other exemplary but comparatively small-scale program in systems interventions points to the inadequacy of simply Achham, an economically disadvantaged district located developing a plan, marshaling the needed resources, and in the Far-Western province in Nepal. The program in- implementing the plan. To achieve sustainable impact at troduced a new, full-time, paid cadre of CHW, working scale, those involved need to critically assess and learn alongside the government CBPHC system. Each CHW from programs done at smaller scale and then apply was responsible for a catchment population of approxi- those lessons, adapting their programs as they imple- mately 2,000. Their primary responsibility was to make — ment further. home visits targeting a variety of groups including pregnant and postpartum women and households with children aged 2 years and younger—for counseling, screening, and referral. To support them in these tasks, a Editor-in-Chief, Global Health: Science and Practice Journal, and Associate they were each issued smartphones equipped with mo- Professor, School of Public Health, University of Alberta, Edmonton, Alberta, Canada. bile apps for documenting services delivered and support- Correspondence to Stephen Hodgins ([email protected]). ing counseling and referral. In addition to conducting

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home visits, the CHWs also helped facilitate twice- literature, offering lessons from strong, nongovern- monthly group antenatal care (ANC) meetings at mental organization-led CHW programs, imple- the local government health post, where they mented at relatively small scale but testing program worked together with project community health design features that are potentially relevant for nurses and health post staff. Besides counseling large government programs. Many of these les- and referral related to pregnancy, postpartum sons are reflected in the recent major World care, family planning, and childhood illness, the Health Organization guidance document1 and CHWs also provided counseling and referral for the CHW Assessment and Improvement Matrix adult chronic diseases. (CHW-AIM).8 The article by Nepal and colleagues focused on We have considerably less documentation in work in 2 municipalities in Achham district (com- the peer-reviewed literature on what works at prising a population of about 60,000), conducted scale for CHW programs. As important as large by 30 CHWs who, in turn, were supported by 8 su- government programs are, they are less easily pervisory staff. This same area has been served by studied, and solid documentation is sparse. A 21 government health posts and 1 primary health very helpful resource has recently been released care center, with approximately 115 full-time on such large national CHW programs9; this com- health workers and 248 female community health pendium includes 29 case studies drawn from volunteers. Although the project coordinated with low- and middle-income countries across 3 conti- local health services, most of the CHW functions nents. They follow a common format, helping facil- were performed independently from the govern- ment CBPHC services, with the exception of the itate comparisons across programs. The case studies group ANC sessions described above. In addition, look at a mix of CHW types, from the more profes- the project regularly reported its service data to sionalized end of the spectrum to less formalized the local health facilities and district and national community health volunteer programs. government reporting systems. In other publica- Case studies of large-scale, institutionalized, tions, the authors have documented evidence public-sector programs—providing good contex- for significant impact of the program, including tual and systems support information and sum- notable improvements in coverage for ANC, marizing available information on their role and institutional childbirth, and postpartum family performance—can be particularly relevant and planning.6,7 useful for national-level policy makers, program Since this initiative began (and indeed before), managers concerned about delivery of services to Nepal has seen a progressive increase in staffing of whole populations, and partners supporting them. government CBPHC services as well as wide test- The set of studies edited by Perry is offered as ing and discussion of alternative models for an introduction to these programs; all of the cases expanding delivery of services at community and either have authors with firsthand familiarity with household levels; this has included a “community the programs or are based on information and auxiliary nurse-midwife” model and “community insights elicited from key informants with such health units” staffed by auxiliary nurse-midwives. experience. Certainly, there are further insights As with the experience addressed in the article by that can be gleaned from the programs documen- Nepal et al., for both of these models, the ted in these case studies. In many instances, there population-to-health worker ratio has been ap- would be value in more analytic work but that will proximately 2,000:1. The article helps to advance require additional primary-level data collection. this discussion in Nepal and offers costing infor- To date, relatively few national CHW programs have been comprehensively assessed. This com- mation that should prove useful for decision pendium should be seen, then, as an invitation to makers at local, provincial, and national levels as dig deeper and learn more from these programs. they consider funding commitments. Important lessons can be learned from both For those engaged in CHW work in other smaller-scale demonstration projects and from country settings, the article provides a good exam- large-scale institutionalized programs. If we are to ple of a costing exercise that was both methodo- logically robust and useful for decision makers. avoid another wave of disappointment with CHW Furthermore, the program the authors describe programs and to see strong CHW programs and has a number of features worth considering else- CBPHC systems operating at national scale, we where, including continuous competency-based need to be looking systematically at both types of training and provision for close supervisory support. program experience: innovating and testing new This article adds to a growing body of published ideas and approaches and looking critically at the

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factors determining performance as programs are mortality: field trial in rural India. Lancet. 1999;354(9194):1955–61. implemented at large scale. CrossRef. Medline 5. Nepal P, Schwarz R, Citrin D, et al. Costing analysis of a pilot com- munity health worker program in rural Nepal. Glob Health Sci Pract. REFERENCES 2020;8(2). CrossRef 1. World Health Organization (WHO). WHO Guideline on Health 6. Maru D, Maru S, Nirola I, et al. Accountable care reforms improve Policy and System Support to Optimize Community Health Worker women’s and children’s health in Nepal. Health Aff (Millwood). Programmes. WHO; 2018. Accessed June 9, 2020. https://apps. 2017;36(11):1965–1972. CrossRef. Medline who.int/iris/bitstream/handle/10665/275474/9789241550369- 7. Citrin D, Thapa P, Nirola I, et al. Developing and deploying a com- eng.pdf munity healthcare worker-driven, digitally-enabled integrated care 2. Black RE, Taylor CE, Arole S, et al. Comprehensive review of the evi- system for municipalities in rural Nepal. Healthc (Amst), 2018; 6 dence regarding the effectiveness of community-based primary health (3):197–204. CrossRef. Medline care in improving maternal, neonatal and child health: 8. summary 8. Furth R, Crigler L, Bjerregaard D. Community Health Worker and recommendations of the Expert Panel. J Glob Health. 2017;7 Assessment and Improvement Matrix (CHW AIM): A Toolkit for (1):010908. CrossRef. Medline Improving CHW Programs and Services. Initiatives Inc. and University 3. Bang AT, Bang RA, Sontakke PG; the SEARCH Team. Management of Research Co.; 2013. Accessed May 27, 2020. https://chwcentral. childhood pneumonia by traditional birth attendants. The SEARCH org/wp-content/uploads/2013/10/CHW-AIM-Toolkit_Revision_ Team. Bull World Health Organ. 1994;72(6):897–905. Accessed Sept13_1.pdf June 9, 2020. https://apps.who.int/iris/bitstream/handle/10665/ 9. Perry H, ed. Health for the People: National Community Health 48645/bulletin_1994_72%286%29_897-905.pdf Programs from Afghanistan to Zimbabwe. Maternal and Child 4. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of Survival Program; 2020. Accessed May 27, 2020. https://pdf.usaid. home-based neonatal care and management of sepsis on neonatal gov/pdf_docs/PA00WKKN.pdf

Received: June 7, 2020; Accepted: June 7, 2020

Cite this article as: Hodgins S. Learning from community health worker programs, big and small. Glob Health Sci Pract. 2020;8(2):147-149. https:// doi.org/10.9745/GHSP-D-20-00244

© Hodgins. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/ 10.9745/GHSP-D-20-00244

Global Health: Science and Practice 2020 | Volume 8 | Number 2 149 COMMENTARY

Beyond No Blame: Practical Challenges of Conducting Maternal and Perinatal Death Reviews in Eastern Ethiopia

Abera Kenay Tura,a,b Sagni Girma Fage,a Alexander Mohamed Ibrahim,c Ahmed Mohamed,d Redwan Ahmed,c Tadesse Gure,c Joost Zwart,e Thomas van den Akker,f,g on behalf of the AMAN-MAMA investigators

neonatal deaths were reported globally, 99% of them in Key Messages low- and middle- income countries and from preventable 2,3 n Performing effective maternal death reviews as causes. A maternal and perinatal death review is one of part of the maternal death surveillance and the key recommended strategies to decrease maternal response program has been hindered by and perinatal mortality by identifying cases and collecting challenges including poor attendance, defensive relevant information permitting an effective response to attitudes, and blame shifting. prevent future deaths.4 With the overall objective of guid- n Reviews of maternal and perinatal deaths should ing actions to eliminate preventable maternal mortality, be based on a “no blame” principle. Emphasis by ensuring that every maternal death (both inside and should be on learning lessons and health outside facilities) is counted to assess progress and evalu- professionals should feel safe to discuss the ate impact of interventions, maternal death surveillance circumstances surrounding death. and response (MDSR) is widely implemented in low- 5 n Meaningful reduction in maternal mortality and middle-income countries. requires a depoliticizing paradigm shift, a Despite its wide uptake guided by the World Health professional body to address patients’ worries, Organization (WHO), a review by Smith et al showed and clear medicolegal guidance to encourage that MDSR is often inadequately institutionalized and providers to identify care deficiencies. the shift from the existing facility maternal death reviews to MDSR was not well addressed.6 Successfully institutionalizing the MDSR requires having strong po- litical commitment, adequate financial support, a strong death identification and notification system, and an ad- BACKGROUND equate legal framework, as well as realizing the “no lthough knowledge on the determinants and causes shame, no blame” culture. Other factors that were Aof maternal and perinatal deaths is well established reported to contribute to the MDSR’s success included and effective strategies to decrease such deaths exist and having professional societies serve as drivers of the pro- are in use, maternal and child mortality comprises the un- cess, professionals’ readiness to serve as member of the finished agenda of the Millennium Development Goals committee or independent assessor, and strong support project.1 In 2017 alone, 295,000 maternal and 2.5 million from national ministries or international agencies like WHO, United Nations Population Fund, or the United a School of Nursing and Midwifery, College of Health and Medical Sciences, Nations Children’s Fund.6 Haramaya University, Harar, Ethiopia. From the program’s beginning, there have been con- b Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands. cerns that introducing the MDSR may have an adverse c Department of Obstetrics and Gynaecology, Hiwot Fana Specialized University effect on existing maternal death reviews and threaten Hospital, Harar, Ethiopia. confidentiality because of its focus on creating change d Department of Paediatrics, Hiwot Fana Specialized University Hospital, Harar, Ethiopia. by improving accountability as opposed to only stressing 7 e Department of Obstetrics and Gynaecology, Deventer Ziekenhuis, Deventer, local care improvements. Initiatives to instigate change Netherlands. through increasing accountability may become a source f Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden University, Leiden, Netherlands. of blame in nonconducive or unsafe environments. In g Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands. such environments, diverting accountability to factors Correspondence to Abera Tura ([email protected]). out of control become the norm to avoid being blamed

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for poor outcomes.8 Such situations have been deaths), and low staff participation.20 Often, fac- Successfully insti- 9–11 reported in several death review practices. tors contributing to bad outcomes (deaths or tutionalizing the Successful maternal death reviews require delays) are stated to be the result of factors outside MDSR requires supportive political and policy environments, in- the control of local health workers and policy having strong 8,15 dividual responsibility and ownership, a proactive makers. political institutional ethos, and promotion of learning as a In a recent qualitative study of MDSR imple- commitment, crucial part of improving services and quality of mentation in Ethiopia, Melberg et al showed that adequate 12 care. In contrast, fear of blame, lack of knowl- highly politicizing maternal deaths, as indicated financial support, “ edge and skills, inadequate resources, missing doc- by the common slogan of no mother should adequate legal die while giving birth” everywhere hinders the umentations, and lack of clear guidelines comprise framework, and a barriers to conduct effective death reviews.13 identification, reporting, review, or assignment of “no shame, no Smith et al stated that successful implementa- causes to maternal deaths. Health workers and blame” culture. tion of MDSR requires building support for the officers leading MDSRs are under so much pres- process in the lower cadres of the health system.14 sure to meet the political requirement of zero ma- However, one of the challenges in the current ternal deaths that there is a strong incentive to MDSR implementation is its weak support at the substantially underreport.8 lower-level facilities where the review process The MDSR system functions without a nation- and identification of response are identified and al confidential enquiry to generate and recom- implemented.15 Lower-level facilities were found mend detailed lessons for practice and merely to receive little support, and many review pro- collates reports that arise from the bottom up 19 cesses were directed toward avoiding conflicts reporting to generate annual MDSR reports. through deflecting responsibility for adverse out- Thus, a safe and just national system of confiden- comes to factors out of control8—thereby affect- tial enquiries could be of added value. Countries, ing both the conclusion and the actions to be like Kenya and Malawi, that have similar MDSR taken to avoid similar deaths in the future. implementation challenges, including inade- quately using the maternal death review process, underreporting of maternal deaths, lack of infor- MATERNAL DEATH REVIEWS IN mation on the response measures taken after a ETHIOPIA maternal death audit, and poor data quality, The practice of maternal death reviews in Ethiopia implemented confidential enquiries as a back- goes back to the 1980s when Kwast et al con- up.10,11 Confidential enquiries can improve the ducted a confidential enquiry of maternal deaths challenges seen in the MDSR by: (1) creating a 16 in Addis Ababa. Since then, only a few death pool of anonymous reviewers, who are not 17 review practices have been reported until the reviewing their own cases unlike MDSR, which 18 MDSR program was introduced in 2013. will judge the practice against a set of standards; Ethiopia is one of the countries where the MDSR (2) having delinked cases from facilities, provi- was initiated to accelerate the reduction in mater- ders, or locations to minimize introducing biases nal mortality as promoted in the 2013 WHO global or the fear of blame during the review process; framework.5 Four annual reports of MDSR imple- and (3) generating national reports and recom- mentation have been produced to date.19 mendations that may influence practice of care or Over the years, similar themes have emerged policy. (delays in decision to seek care, delays in reaching Given the increases in infrastructure and hu- appropriate facility, or not receiving appropriate man capital in Ethiopia,22 improvements in the Improving care care in facilities), and direct obstetric conditions provision of care would be expected, thereby re- should first focus are still the predominant cause of maternal ducing the mortality and morbidity. Improving on evaluating the 16,17,20 deaths. Shortages of supplies and equip- care should first focus on evaluating the quality of quality of care ment continue to be reported to contribute to a care after clients reach the facilities (delay 3) rath- after clients reach majority of the deaths. In a study from facilities in er than on problems in the community and en the facilities. Northern Ethiopia, only slightly more than half of route to the facilities.23 But, the existing practice the facilities were practicing good quality death seems to focus on the delays in deciding to seek reviews and took proper action for identified pro- care (delay 1) and delays in reaching care (delay blems.15 The Ethiopian MDSR, although reported 2), which are partly out of the control of reviewing as a success by some21 is characterized by low health staff and facility and sometimes totally out- coverage (captured 7.4% of expected maternal side the realm of the health system.15 Previous deaths), low review (reviewed 8% of identified reviews indicated that focusing on delay 1 and

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2 could mask effective design of implementation even learn that referred women had passed away by focusing more on outside factors.24,25 Such due to absence of appropriate feedback from reviews would result in generating unrealistic higher to lower levels of care.29 recommendations as the factors are outside of Reviews of maternal and perinatal deaths their sphere of influence. should be based on a “no blame” principle.4,30 Emphasis should be on learning lessons, and THE PRACTICAL CHALLENGES IN health professionals should feel safe to discuss the circumstances surrounding each death.4 To im- EASTERN ETHIOPIA prove the quality of maternal death reviews, the On paper, maternal death reviews have been con- averting maternal and neonatal morbidity and ducted in Eastern Ethiopia as part of the national 18,20 mortality through obstetric audit (AMAN-MAMA) MDSR program. In practice, performing effec- project was started in 2018 in selected hospitals in tive death reviews suffered from poor attendance Eastern Ethiopia. As part of this program, 2 mater- and a defensive attitude among participants, look- nal and perinatal death review sessions were con- ing for deficiencies in care before a woman ducted, one in September 2018 and a second one reached the hospital. This resulted in common- in January 2019. The sessions were well attended “ place observations such as lack of antenatal by staff from all cadres from hospital management ”“ care, lack of awareness about danger signs in to health center staff, as well as experienced inter- ”“ ” “ the woman, late referral, or absent prereferral national assessors, all participants showed great ” management, which appear to transfer responsi- motivation from all participants to contribute to bility for bad outcomes to the woman and refer- case assessments, and learning and self-reflection 20,26,27 ring facilities. In addition, existing death were emphasized. During both sessions, unfore- reviews did not include perinatal deaths yet con- seen incidents hampered an effective audit process trary to the change of MDSR to maternal and peri- and forced the authors to consider that a “no natal death surveillance and response. Such blame” attitude during a maternal death review challenges of not adequately reviewing perinatal now collides with daily realities in Ethiopian life. 15,28 mortality has been reported previously. Given In September 2018, on the third day of the or- the high burden of maternal mortality in many ganized sessions, an attendee—a staff member at a low-resource countries, effective perinatal death neonatal care unit—did not show up to the session 15 review will not be within reach in a shorter time. because he had been blamed and jailed for a pedi- Moreover, learning during the audit was ham- atric death. He was later released from custody pered by political sensitivities surrounding mater- and charges were dropped. In addition, during nal death—a desire for no maternal deaths by the second maternal death review meeting held political leaders and higher officials in hospitals or in one of the hospitals, a police officer, who was 8 health bureaus. No or few maternal deaths were the partner of a woman receiving care, attacked reported to occur in referring hospitals and health the attending physician in the labor ward because centers, while “(near-) death on arrival” was ob- he did not want his wife to give her informed con- served to be a common problem in the majority sent for a cesarean delivery to be performed. His of the referral hospitals. At the lower-facility level, attack turned the hospital grounds into a violent a woman in very critical condition sometimes scene with groups of people attacking one anoth- appeared to be referred out immediately, some- er, thus the circumstances for the maternal review times without starting prereferral life-supporting session suddenly changed from ideal to impossi- care, out of fear that she would die at that facility. ble. These incidents illustrate how the realities in Such women will be registered by receiving facili- many low- and middle- income countries, such as ties as “death on arrival.” These deaths will mostly lack of infrastructure to assess professional con- not be reviewed by the receiving hospitals’ death duct and sudden interference by the public or po- review committee since they are thought to be lice, may hamper feelings of safety to discuss bad the result of deficient care at the community level outcomes among health professionals. or at the level of referring facilities or because In a country on its long way to become a dem- available information and documentation were ocratic state, civil unrest, lack of a professional insufficient for conducting a death review. body to address patients’ worries regarding quality Moreover, at the lower facilities, these deaths sub- of health care, and absence of clear medicolegal sequently end up being forgotten since the refer- guidance in general31 hamper professionals to ring facility will not perform a death review—but come forward and identify care deficiencies. Such are reported as referred cases—and will mostly not factors comprise a threat to the advances that are

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being made in Ethiopia and many other emerging Maternal Death. Geneva: WHO; 2013. Accessed March 1, 2020. economies at present in improving pregnancy http://apps.who.int/iris/bitstream/10665/87340/1/ outcomes for their populations.32 There should 9789241506083_eng.pdf?ua=1 be an agreement on the best societal outcomes 6. Smith H, Ameh C, Roos N, Mathai M, Broek NVD. Implementing maternal death surveillance and response: a review of lessons from and collaboration between public health and law country case studies. BMC Pregnancy Childbirth. 2017; 17(1):233. 33 enforcements to improve health. These scenari- CrossRef. Medline os underline the importance of addressing medi- 7. De Brouwere V, Lewis G, Filippi V, et al. Maternal death reviews. colegal aspects of death reviews both in principle Lancet. 2013;381(9879):1718–1719. CrossRef. Medline 31 and practice. 8. Melberg A, Mirkuzie AH, Sisay TA, Sisay MM, Moland KM. ‘Maternal deaths should simply be 0’: politicization of maternal death reporting and review processes in Ethiopia. Health Policy Plan. THE WAY FORWARD 2019;34(7):492–498. CrossRef. Medline Although ending preventable maternal mortality 9. Armstrong CE, Lange IL, Magoma M, Ferla C, Filippi V, Ronsmans C. requires political priority,34 direct interference in Strengths and weaknesses in the implementation of maternal and perinatal death reviews in Tanzania: perceptions, processes and the health system may not accelerate progress – 8 practice. Trop Med Int Health. 2014;19(9):1087 1095. CrossRef. and may even deter the situation. In a country Medline where maternal mortality is a highly political phe- 10. Abouchadi S, Zhang WH, De Brouwere V. Underreporting of deaths 8,35 nomenon, meaningful reduction in maternal in the maternal deaths surveillance system in one region of Morocco. mortality requires a depoliticizing paradigm shift. PLoS One. 2018;13(1):e0188070. CrossRef. Medline Health care providers should work within a con- 11. Agaro C, Beyeza-Kashesya J, Waiswa P, et al. The conduct of ma- ducive environment that enables them to thor- ternal and perinatal death reviews in Oyam District, Uganda: a de- scriptive cross-sectional study. BMC Womens Health. 2016;16:38. oughly evaluate the pathways to death and CrossRef. Medline generate lessons using their own perspectives, 12. Lewis G. The cultural environment behind successful maternal death rather than using the narrow political lens of and morbidity reviews. BJOG. 2014;121 Suppl 4:24–31. CrossRef. achieving the “no mother should die while giving Medline birth” slogan everywhere and every time. 13. Lusambili A, Jepkosgei J, Nzinga J, English M. What do we know about maternal and perinatal mortality and morbidity audits in sub- Saharan Africa? A scoping literature review. Int J Human Rights Acknowledgments: AMAN-MAMA investigators are Abera Kenay – Tura, Sicco Scherjon, Jelle Stekelenburg, Jos van Roosmalen, Joost Healthcare. 2019;12(3):192 207. CrossRef Zwart, and Thomas van den Akker. The content and views expressed by 14. Smith H, Ameh C, Godia P, et al. Implementing maternal death sur- the authors in this publication do not necessarily reflect the views of veillance and response in Kenya: incremental progress and lessons Laerdal Foundation. learned. Glob Health Sci Pract. 2017;5(3):345–354. CrossRef. Medline Funding: The maternal and perinatal death review was funded by 15. Ayele B, Gebretnsae H, Hadgu T, et al. Maternal and perinatal death Laerdal Foundation (ref no: 40241) as part of the AMAN-MAMA surveillance and response in Ethiopia: achievements, challenges and project. prospects. PLoS One. 2019;14(10):e0223540. CrossRef. Medline Competing interests: None declared. 16. Kwast B, Bekele M, Yoseph S, Gossa A, Mehari L, Frost O. 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Published Reviewing Maternal Deaths and Complications to Make Pregnancy December 2017. Accessed April 28, 2020. Safer. Geneva: WHO; 2004. Accessed March 1, 2020. http:// 21. Abebe B, Busza J, Hadush A, et al. ‘We identify, discuss, act and whqlibdoc.who.int/publications/2004/9241591838.pdf?ua=1 promise to prevent similar deaths’: a qualitative study of Ethiopia’s 5. World Health Organization (WHO). Maternal Death Surveillance maternal death surveillance and response system. BMJ Glob Health. and Response: Technical Guidance Information for Action to Prevent 2017;2(2):e000199. CrossRef. Medline

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22. Souza JP, Tunçalp Ö, Vogel JP, et al. Obstetric transition: the path- 29. Abate B, Enquselassie F. Information use in patients’ referral system way towards ending preventable maternal deaths. BJOG. 2014;121 at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. Suppl 1:1–4. CrossRef. Medline Ethiop Med J. 2010;48(2):123–135. Medline 23. Vora KS, Saiyed SL, Yasobant S, Shah SV, Mavalankar DV. Journey 30. Ethiopian Public Health Institute. National Technical Guidance for to death: are health systems failing mothers? Indian J Community Maternal and Perinatal Death Surveillance and Response. https:// Med. 2018;43(3):233–238. CrossRef. Medline www.ephi.gov.et/images/pictures/National-Maternal-and- – 24. Gunawardena N, Bishwajit G, Yaya S. Facility-based maternal Perinatal Death-Surveillance-and-Response-guidance-2017.pdf. death in western Africa: a systematic review. Front Public Health. Published 2017. Accessed April 28, 2020. 2018;6:48. CrossRef. Medline 31. Bain LE, Kongnyuy EJ. Legal and ethical considerations during ma- 25. Knight HE, Self A, Kennedy SH. Why are women dying when they ternal death surveillance and response. Afr J Reprod Health. – reach hospital on time? A systematic review of the ‘third delay’. PLoS 2018;22(2):17 25. CrossRef. Medline One. 2013;8(5):e63846. CrossRef. Medline 32. Bandali S, Thomas C, Hukin E, et al. Maternal death surveillance 26. Ethiopian Public Health Institute. National MDSR Annual Report and response systems in driving accountability and influencing – 2008 EFY. http://mdsr-action.net/wp-content/uploads/2017/04/ change. Int J Gynaecol Obstet. 2016;135(3):365 371. CrossRef. National-MDSR-Annual-Report-2008-EFY_Final.pdf. Published Medline January 2017. Accessed April 28, 2020. 33. van Dijk AJ, Herrington V, Crofts N, et al. Law enforcement and 27. Ethiopian Public Health Institute. National MDSR Annual public health: recognition and enhancement of joined-up solutions. – Report 2006-2007 EFY. https://www.ephi.gov.et/images/ Lancet. 2019;393(10168):287 294. CrossRef. Medline pictures/download2009/First%20NationalMDSR%20Report% 34. Shiffman J, Smith S. Generation of political priority for global health 202007%20EFY.pdf. Published July 2016. Accessed April 28, initiatives: a framework and case study of maternal mortality. Lancet. 2020. 2007;370(9595):1370–1379. CrossRef. Medline 28. Bandali S, Thomas C, Wamalwa P, et al. Strengthening the “P” in 35. Ostebo MT, Cogburn MD, Mandani AS. The silencing of maternal and perinatal death surveillance and response in Bungoma political context in health research in Ethiopia: why it should be a county, Kenya: implications for scale-up. BMC Health Serv Res. concern. Health Policy Plan. 2018;33(2):258–270. CrossRef. 2019;19(1):611. CrossRef. Medline Medline

Peer Reviewed

Received: October 22, 2019; Accepted: March 24, 2020; First published online: May 27, 2020

Cite this article as: Tura AK, Fage SG, Ibrahim AM, et al. Beyond no blame: practical challenges of conducting maternal and perinatal death reviews in Ethiopia. Glob Health Sci Pract. 2020;8(2):150-154. https://doi.org/10.9745/GHSP-D-19-00366

© Tura et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/ 10.9745/GHSP-D-19-00366

Global Health: Science and Practice 2020 | Volume 8 | Number 2 154 VIEWPOINT

Coping With COVID-19: Learning From Past Pandemics to Avoid Pitfalls and Panic

Daniel T. Halperina

Key Messages over time and difficult to walk back, even after new evi- dence appeared. Well-meaning but overly simplistic n As we wrestle with how best to mitigate COVID- messages such as, “always use a condom with anyone 19, it is imperative to concur on the likely main or die” inadvertently created other problems.1,3,4 Earlier drivers of transmission (notably, infection clusters openness to innovative approaches, such as male resulting from prolonged indoor respiratory ex- circumcision and addressing sexual networks, could posure) in order to clearly explain risk and to have saved many lives, particularly in sub-Saharan determine the most effective, realistic behavioral Africa.1,2,5 In subsequent years, as greater funding for re- and other means to reduce illness and mortality. search and treatment eventually poured in, a kind of n At the same time, we must avoid generating “AIDS exceptionalism” also became imbedded.6 irrational fear and maintain a broader perspective, During the first years of the AIDS response, much including assessing the possibility for substantial was unknown regarding the causes and main modes unintended consequences from the response to of transmission. Yet, even after HIV was identified in the pandemic. 1983 and the basic science became clearer, a great deal of uncertainty, persecution of marginalized groups, and terror persisted. Rumors proliferated that anything from mosquitoes to using contaminated condoms to sharing toothbrushes were spreading the virus. In the UNCANNY SIMILARITIES WITH THE LAST 1990s, after Earvin “Magic” Johnson tested positive for MAJOR PANDEMIC HIV, counseling centers became overrun by the “worried 1,3 n June 1981, when the first cases were reported of well.” Heterosexual college students flooded centers Iwhat became known as AIDS, I was living in the San to get tested, petrified from having engaged in deep kis- Francisco Bay area. As the waves of death mounted, I sing or intimate touching “without protection,” thereby volunteered at a hospice in Oakland, California, and lat- diverting attention from those who were actually at sig- er conducted epidemiological research at the University nificant risk of infection. of California. There are major differences between HIV and severe CONFUSION AND PANIC RETURNS WITH acute respiratory syndrome coronavirus 2 (SARS-CoV- THIS PANDEMIC 2) and their resulting pandemics (AIDS and coronavirus With COVID-19, much remains unclear, but some basic disease ([COVID-19]). However, I’m having déjà vu: facts are known and more emerge daily. Yet, a palpable from the devastating number of deaths and the perva- climate of confusion and anxiety pervades. (One mind- sive atmosphere of confusion, fear, and often panic. boggling indication is that the Johns Hopkins University Tragically, political leaders from Ronald Reagan to Coronavirus Resource Center website is recording some Nelson Mandela were slow to respond to the AIDS 4 billion hits a day!7) Under such circumstances, fear is epidemic. All sides engaged in acrimonious ideological understandable and can help motivate behavior warfare that often ignored the epidemiological evide- change.1,8 However, when fear becomes irrational or nce. In hindsight, health authorities also made some leads to panic, it often results in poor decision making decisions—especially under the pressure of needing to and other unintended consequences.9,10 Moreover, act immediately—that led to suboptimal and ultimately there are troubling signs that we have failed to learn oth- costly outcomes.1,2 Policies often became hardwired er important lessons from the previous pandemic, in- cluding the danger of polarized infighting. For example, a Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA. politicians and the media as well as some medical experts Correspondence to Daniel Halperin ([email protected]). are presenting us with a false dichotomy: having to

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choose between recklessly abandoning mitigation illnesses such as diabetes and heart disease,14–16 efforts to reopen the economy versus rigidly con- more so in men and particularly when exacerbat- tinuing present lockdown measures. ed by obesity and smoking.17,18 It may be that The U.S. territory of Puerto Rico where I reside Indeed, it may be that advanced age alone, in advanced age implemented a nearly complete shutdown in mid- the absence of such predisposing conditions, is alone, in the March after the first death here (of an Italian less of an independent risk factor than has been as- absence of cruise ship passenger). Since then, many people, sumed. Firstly, the elderly are more likely to have preexisting convinced the virus is “everywhere” and infection chronic illnesses, which confounds the association conditions, is less is nearly unavoidable, won’t leave their homes between outcomes and age. Moreover, the fact 16 of an independent even to pick up groceries. When delivery services that between 96% (in the United States ) and 14 risk factor than became overwhelmed, elderly and sick persons more than 99% (in Italy ) of COVID-19-related has been sometimes have not been able to obtain essential deaths, at any age, have occurred in persons with assumed. supplies. Most of those who do drive or go out- preexisting conditions could suggest that even doors use masks (needlessly) even when far away very old but otherwise healthy people may not be from other people. Wearing masks in the hot, hu- at greatly elevated risk of dying from the disease. mid climate can be uncomfortable and has created Further research and analysis, including assessing issues, including elderly persons fainting while whether the important angiotensin-converting waiting in the sun for a long time to enter stores enzyme 2 protein (ACE-2) is more prevalent in (which often only allow a handful of customers the elderly19 could help explain the often higher to enter at once). Until recently, joggers and others infection (not only higher mortality) rates in older were stopped and occasionally fined by police for populations.20 In any case, such data underscore venturing outside or for violating the 7 pm curfew, the ongoing need in general to prioritize preventing which remains in effect after nearly 3 months. chronic diseases, which kill more than 40 million (Even in most of the world’s hardest-hit countries, people annually (over 80% in lower- and middle- such as Spain and Italy, people are now allowed income countries),21 and to address underlying outdoors to exercise.) Numerous restaurants, conditions such as obesity and smoking.22,23 especially Asian-owned ones, have closed after losing takeout customers. Some stores require CLEAR EVIDENCE-BASED customers to wear gloves, despite evidence sug- gesting limited utility or that their use may actual- INFORMATION IS OFTEN LACKING 11 Regarding COVID-19 prevention, it is imperative ly increase risk of infection. for experts to agree on what are the likely main transmission routes and to carefully determine WHAT ARE THE MAIN RISK FACTORS which are, accordingly, the most effective (and re- FOR SEVERE OUTCOMES? alistically achievable) behavioral and other ways It is probable that In Puerto Rico, as in other parts of the world, to reduce morbidity and mortality. It is probable that, as with other illnesses such as in- most infections many people (even many youth) with asthma are respiratory fluenza, most COVID-19 infections occur from occur from close terrified of experiencing severe outcomes if they exposure to close exposure to coughing, sneezing, shouting, become infected with the virus, prompting singing, or other direct and coughing, relatively prolonged shortages of inhalers and other critical supplies. contact with someone who is symptomatic or sneezing, The U.S. Centers for Disease and Prevention presymptomatic. (There is evidence that some shouting, singing, (CDC) website lists people with asthma near the asymptomatic carriers are contagious, but from or other direct and top of those at risk of severe COVID-19 outcomes, existing studies they appear not to represent a prolonged contact even though only 1 clinical study has investigated very substantial proportion of total COVID-19 with an infected whether a relationship exists and has found no transmission.) person. link.12 Although other emerging data strongly ap- In February, a team of World Health Organi- pear to confirm the lack of an association,13 it is zation (WHO) researchers led by David Heymann unclear whether the CDC will correct its public investigated the outbreak in Wuhan, China, and information. concluded that the large majority of transmission What is clear, based on evidence from several events occurred within indoor clusters24 between countries (and despite media attention to statisti- family members (accounting for 75%–85% of cally anomalous cases of healthy and younger vic- estimated infections) and coworkers, with no iden- tims), is that severe outcomes and deaths from tified cases of child-to-adult transmission identi- COVID-19 are overwhelmingly associated with fied.15 In addition, some data suggest that severity preexisting (and especially multiple) serious of outcomes is associated with initial exposure

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viral-load levels.24–26 Moreover, it increasingly quarantine residences, as several Asian countries appears that infection risk from contaminated sur- and Iceland have successfully instituted.35–37 faces has been at least somewhat overstated, as the Delays in seeking care not only diminish survival CDC recently acknowledged.27 Indeed, it is con- chances but also expose household members to Future historians ceivable that future science historians may con- significant infection risk.14,35,36,38 may conclude that clude that many current COVID-19 prevention many current strategies had little if any impact, particularly be- IS 6 FEET DISTANCING STRICTLY prevention cause they targeted drivers of spread accounting strategies had for no more than a small proportion of total NECESSARY? little impact One example of inconsistent public health mes- infections. because they saging is that European and Asian authorities and targeted unlikely the WHO recommended physical distancing based drivers of HIGH RISK, LOW RISK, OR NO RISK on data that droplets containing the virus had infection. OF TRANSMISSION been identified almost a meter away from cough- 1,4 As some experts eventually did with HIV, they ing individuals. In the United States, for some rea- could also help the public distinguish between son 1 meter was initially translated into 5 feet and those behaviors and situations posing the highest subsequently became “over 6 feet.” Although per- risk for COVID-19 infection, those of likely lower haps arguably not the highest priority, it would be risk (such as the virus lingering on hard surfaces useful for the CDC and other experts to determine for extended periods), and those of highly unlikely whether such abundance-of-caution guidance is or no risk (such as being outdoors with no one else worth maintaining or perhaps is not scientifically around). Although the CDC has posted some basic warranted, and may inadvertently feed excessive guidance on its website (in the Frequently Asked concern. (In fact, the entire concept of physical or The pertinent Questions section) regarding how COVID-19 is “social” distancing is not specifically relevant to factor is not the mainly transmitted, the public would benefit transmission risk, primarily related to respiratory physical distance 28 from a more clearly communicated and much droplets: the pertinent issue is not the distance between people's more robust public information campaign (e.g., per se between people's bodies but rather between bodies, but rather including the virtual equivalent of placing a leaflet their faces, particularly if unmasked. For example, the distance under every U.S. resident’s door). This would help if 2 people are positioned back-to-back, then obvi- between their reduce time and attention spent addressing low- ously the distance can safely be much less.) faces. risk concerns, such as when healthy people avoid This issue of distancing is particularly relevant leaving home for necessary activities even if care- as weather improves and outdoor exercise fully taking precautions. becomes more common, as many health depart- There is a crucial distinction between risk ments28,30,39 encourage people to do (even There is a crucial of indoor transmission—where physical distanc- though a hypothetical model based on untested distinction ing (whether mandated or voluntary) and perhaps assumptions sparked alarm by suggesting that jog- between risk of other measures28,29 are critical—versus risk of gers or cyclists could spread the virus over greater indoor 40 outdoor transmission, which is far lower (possibly distances ). And critically, as the economy begins transmission, by an order of magnitude) for various reasons, in- to reopen, it would be especially challenging for where physical cluding dissipation of droplets in the air28,30 and some businesses (and eventually schools) to ad- distancing is here strictly to a 6-foot rule. This could be particu- the deactivating effects of ultraviolet radiation critical, versus the 31–33 larly excessive for outdoor activities, including and heat. A contact tracing study from China risk of outdoor construction, farming, recreation, and outdoor found that 80% of infections involved household dining. It is certainly more practical to maintain a transmission, members and 34% involved mass transit (multiple distance of about 3 feet than 6 feet in many situa- which is far lower. potential transmission routes were considered), tions, such as grocery shopping (where interac- whereas only a single infection event of the tions are typically brief) or while strolling with a 7,324 cases investigated was linked to casual out- companion. door transmission.28,30,34 Although politicians and the media have been obsessed with the danger of frolicking on beaches COVID-19 AND CHILDREN: MUST (or of participating in protest gatherings), a vastly SCHOOLS REMAIN CLOSED? greater risk is the common (public health) admo- Indeed, it is likely that more “surgical”—more nition for sick persons to remain home as long as carefully targeted and realistic, evidence-based possible before seeking hospital care, without pro- approaches4,41–43—could be similarly efficacious viding access to alternative, clinically-provisioned as more extreme isolation strategies that have been

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widely implemented. For example, Singapore had before people began getting infected) were analyzed, initially achieved a notably effective response with- about half the people studied appeared to already out shutting schools.44 (However, subsequently have some protective T-cell immunity to the new vi- there was a surge in cases due to an outbreak in rus, resulting from past exposure to other corona- crowded migrant-worker dormitories.) Taiwan, viruses.60 Importantly, young people also produce which never closed its schools, has continued to re- smaller amount of the aforementioned ACE-2 protein, port very few cases. a critical nasal cell entry point for both SARS Similar to the first severe acute respiratory viruses.19,47,52 45,46 Growing evidence syndrome (SARS) epidemic in 2002–2004, Moreover, the evidence suggests that even when suggests that the vast majority of children infected with SARS- children do become infected, they are probably con- 46,53–58,62 children are less CoV-2 escape severe outcomes. There has been siderably less contagious than adults. Are- likely to become much media attention to multisystem inflamma- cent German study found viral loads in infected children at levels comparable to adults. However, infected. Even if tory syndrome in children (MIS-C), which has features similar to Kawasaki disease. However, of the number of children studied was very small and they become other methodological concerns have been raised. infected, they are the more than 7 million COVID-19 infections reported worldwide to date, only a few hundred More importantly, although for some pathogens less contagious cases of MIS-C have been identified so far.47,48 (such as HIV) viral load is highly associated with in- than adults. fectivity, the implications of viral load for COVID-19 (Although the usual Kawasaki disease is more clinical progression and contagiousness remain common in East Asia, in the United States about unclear.53,54,61 Because the many asymptomatic 5,000 cases occur annually.48) Of more than youth infected with COVID-19 are not coughing or 400,000 COVID-19 deaths reported worldwide, sneezing, they emit far fewer infectious droplets. some 20 children are known to have died, about And remarkably, contact tracing studies conducted half of them in the United States and the rest in in China, Iceland, Netherlands, and United Kingdom Europe. By comparison, more than 200 children have failed to identify a single case of child-to- died last year from the flu in the United States adult infection of thousands of transmission events alone, along with some 10,000 others from vari- analyzed.15,36,52–57 A review of household transmis- ous childhood diseases.49 Further contextualizing sion studies from several Asian countries concluded the MIS-C and other childhood deaths from that less than 10% of household clusters involved a COVID-19, in the United States, per-capita mortal- child index case,62 and a analysis of different ity in persons aged 85 years and older is 2,000 times COVID-19 interventions in the United States found 63 higher than in children aged 15 years and youn- no evidence for the impact of school closures. ger.50 (An intriguing question posed by some It should be noted that some of these data researchers is whether MIS-C is definitely or al- probably underestimate children’s actual conta- ways caused by COVID-19, considering that in giousness, as they were collected after lockdowns some cases up to one-third of afflicted children and other mitigation measures had been imple- have tested negative for COVID-19, both on poly- mented. However, the striking findings from the merase chain reaction and antibody tests.51) contact tracing studies in particular, as well Although the emerging MIS-C must be closely as the evidently significant biological differences monitored, as with Kawasaki disease most cases ap- between COVID-19 and other respiratory pathogens, pear to recover fairly rapidly, especially if detected suggest that children are not major sources of infec- and treated early.46–48 tion, especially as compared to the common cold Because young people typically come in con- strains of coronaviruses, for example. tact with many other children and adults, they Even without the substantial amount of data are often efficient spreaders of respiratory patho- that emerged subsequently (which presumably gens. However, growing evidence suggests that, would have reduced the predicted impact of as with the earlier SARS,45,46 children are less like- school closures), in March 2020, modelers from ly to become infected with SARS-CoV-2.52–58 the Imperial College of London estimated that According to the CDC, only about 1.5% of U.S. closing schools might prevent only 2%–4% of pre- cases of COVID-19 have been reported in persons mature deaths in the United Kingdom (i.e., pre- aged 18 years or younger.59 Researchers theorize dominantly of older adults with predisposing that previous exposure to other coronaviruses conditions such as chronic diseases, obesity, and (e.g., those producing many of the common colds smoking, who could become directly or indirectly frequently acquired by children) may confer some infected from schoolchildren.)64 In contrast, the partial resistance to SARS-CoV-2.47,52,54 Interestingly, modelers estimated that 17%–21% of total deaths when blood samples collected before fall 2019 (i.e., can be prevented from self-quarantining at home.

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In Denmark, Norway, and New Zealand, uncommon, which—although most experts be- If previous where schools reopened in April 2020, the num- lieve is quite probably the case—remains uncon- infection does not 83,84 bers of new COVID-19 cases have continued to firmed. Note that if previous infection does provide immunity, fall, similar to trends in Finland, France, not confer immunity, it may prove very difficult vaccines are also Germany, Netherlands, and Vietnam, where to develop a vaccine that does so. unlikely to work. schools all reopened in mid-May or earlier This sort of herd-immunity approach could (though cases have increased in Madagascar, but be strongly enhanced by large-scale antibody perhaps not mainly due to reopening schools). It testing to identify previous infection, as China, will, of course, be vitally important to implement Germany, Spain, United Kingdom, and some U.S. adequate testing and safety measures for teachers locales have begun to implement.85,86 Crucially, and other school employees68,69 and to closely we must determine how best to isolate or other- Crucially, we must monitor the data as schools also begin reopening wise protect the most vulnerable populations determine how in Australia, Israel, Japan, and elsewhere (even as from infection—certainly no easy task. If it were best to isolate or some U.S. school districts and colleges have an- to be the case, as previously discussed, that elderly otherwise protect nounced that fall 2020 instruction will be con- but otherwise healthy people are not actually at con- the most ducted strictly online). (In Switzerland, health siderably greater risk of severe illness or death, then vulnerable authorities also announced permission for grand- clearly this would make the challenge somewhat populations from parents to hug their young grandchildren.70) less daunting. However, the evidence is not yet infection— Certainly, as decisions are made regarding the sufficient to base policy on this still-hypothetical certainly no easy reopening of schools, it must be taken into ac- possibility. task. count that school closures have been depriving Although obviously far from ideal, something over a billion students worldwide of essential akin to such an alternative approach may emerge classroom learning, vital social connections, and (including perhaps in some lower-income regi- physical activity. In addition, socioeconomic dis- ons) as one of the least terrible, more realistic parities are increasingly exacerbated, as some fam- longer-term alternatives, until a vaccine is avail- ilies have the technological, parental academic able. Interest in such strategies is intensified by assistance, and other resources to enhance online the potential for a resurgence of infections once learning, while less privileged children fall further containment measures are eased, including a pos- behind.54,55,58,71 Other huge consequences of sible second wave in late 2020 and early 2021. school closures include documented surges in Outcomes will need to be rigorously assessed in child abuse; hunger from missed subsidized meals; places like Sweden, where despite most businesses and greater anxiety, depression and isolation, and schools having stayed open, COVID-19 deaths School closures which often are most acutely experienced by stu- have been declining, though not as sharply as in have deprived dents with autism, Down syndrome, attention- most other European countries.87 over a billion deficit/hyperactivity disorder and other special students of needs challenges.71–80 academic WHAT CAN WE LEARN FROM PLACES progress, social THAT DID NOT IMPOSE A FULL ONE ALTERNATIVE TO LOCKDOWN: connections, LOCKDOWN? physical activity, MOVING TOWARD HERD Ongoing attention has focused on Sweden’s per- and subsidized IMMUNITY? capita death rate being much higher than in other meals. Although many experts continue to believe that stay- Scandinavian countries. However, a crucial differ- in-place measures are needed to flatten the curve, ence is that in Sweden most reported cases (not others have proposed a Phase 2 alternative—instead only deaths) have occurred heavily among the el- of attempting to prevent any new infections—of derly,20 particularly those residing in long-term essentially allowing younger and healthier people care homes—similarly to the situation in Belgium, to gradually return to work and school, based on a France, Italy, Netherlands, Spain, and the United herd-immunity strategy.43,44,81,82 Although many Kingdom.50,87,88 Those countries (and, for exam- of them could eventually become infected, most ple, the New York/New Jersey area) all have higher individuals would be expected to experience rela- reported death rates than Sweden, despite tightly tively mild to moderate symptoms and, ideally after locking down since at least late March 2020. That self-quarantining, would effectively be “naturally Sweden’s COVID-19 mortality is lower than in vaccinated” (i.e., they would presumably no longer those European countries becomes even more evi- be contagious, for perhaps a year or more). Such an dent if comparing via excess mortality (current approach assumes, of course, that reinfection is deaths compared to typical levels in preceding

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years) instead of relying on official mortality data. rural) states began reopening, turned out to be Belgium and Sweden are 2 European countries considerably overdrawn.93,95 that appear to have maintained near completely ac- A key implication of the experience from the curate data on COVID-19 mortality.89 Thus, al- 5 non-lockdown U.S. states and Sweden is not though official statistics would suggest, for that death rates in those places have been lower example, that Belgium’s death rate is not only the than elsewhere, but if outcomes generally have world’s highest but is about double that of neigh- not been worse, this suggests that similar results boring Netherlands’, if instead the comparison is may be achieved at a less drastic economic and so- based upon excess mortality, the 2 countries’ actual cietal cost. (In the case of Sweden, a fairer compar- death rates appear much more similar.89 (It could, ison would be to more epidemiologically similar therefore, be mistaken to conclude that Belgium's European countries, rather than utilizing the mitigation efforts have necessarily been inferior to “ecological fallacy” of comparing its experience The urge to apply the Netherlands’ since the more pertinent explana- only to the other Scandinavian nations.) In any an either/or, one- tion may simply involve an issue of data reporting case, the urge to apply an either/or, one-size-fits- size-fits-all quality.) Very importantly, all of the aforemen- all approach, which also hampered the response 1,2,4,5 approach should tioned places, including Sweden, have failed to im- to AIDS and some other past health crises, be resisted. plement adequate control measures in elderly should be questioned, including in lower- and residences.50,87,88 Whereas in Denmark and middle-income world regions.93,96–100 Norway, similar to the situation in Germany, Japan, and South Korea, a much larger proportion UNINTENDED CONSEQUENCES OF of infections has for some reason occurred in rela- tively younger people,20 consequently resulting in THE GLOBAL LOCKDOWN COULD BE considerably lower COVID-19 death rates. MASSIVE Apparently also very salient, if rarely men- It is crucial that an evidence-based and transpar- 41 tioned, is that recent immigrants in Sweden have ent debate underpin decisions, obviously taking suffered disproportionally far greater infection and into consideration the unprecedented conse- mortality rates, reportedly due in part to insuffi- quences of financial collapse and lost income ciently targeted prevention campaigns.90,91 By one resulting from a prolonged economic shut- 9,44,82,99–105 estimate, perhaps 40% of all COVID-19 deaths in down, as most painfully experienced the capital city, Stockholm, have been solely among socioeconomically disadvantaged popula- tions.106 Such disruptions are being felt most among Somali refugees (who comprise a minority dangerously in the lowest-income regions of sub- of foreign-born immigrants in the city, after Iraqis, Saharan Africa and South Asia, where the pros- Syrians, and Afghans, in that order).90 Non- pect looms for unintended consequences of European residents also comprise—differently – harrowing proportions.73,96 102,105,107 These in- than the case elsewhere in Scandinavia—the ma- clude potentially vast increases in deaths from ma- ’ 90 jority of the country s nursing home employees. laria, tuberculosis, measles, polio, diarrheal and Although certainly understandable, the possible other diseases, and malnutrition, as vaccination, fear by the Swedish government of a xenophobic maternal and child health, family planning, and or Islamophobic backlash may, however, have other basic services are suspended due to lock- resulted in grave public health consequences, rem- downs or are deprioritized while health efforts iniscent of prevention campaigns during the earlier increasingly focus on COVID-19.71,96–99,108–113 AIDS years that shifted attention, also understand- Considering that young children are likely to be ably but similarly deleteriously, away from those at particularly impacted, this would represent an highest risk to avoid homophobia and discrimina- even greater magnitude of devastation if mea- It is noteworthy tion against marginalized groups.1,3 sured in terms of years-of-life-lost, and not only that in the 5 U.S. It also appears noteworthy that in the 5 U.S. via crude mortality numbers. states that never states that never imposed stricter isolation mea- The catastrophic number of deaths directly imposed stricter sures,92 observable increases in new cases have resulting from COVID-19—which eventually may isolation not occurred, as compared to demographically eclipse the estimated 1 million from the “Hong measures, and otherwise similar neighboring rural states Kong” flu in 1968–1969,114 (when the world’s observable that implemented tight lockdowns.93 This obser- populationwaslessthanhalfoftoday’s)—along increases in new vation is consistent with the fact that modeling with the many who could suffer long-term se- cases have not predictions in late April 2020 of a sharp uptick of quelae,115,116 must be considered alongside the in- occurred. death across the United States,94 as many (largely creased mortality and compromised outcomes for

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Accessed May 26, who-estimates-malaria-deaths-could-double-because-of- 2020. https://www.nytimes.com/2020/05/04/us/coronavirus- interruptions-caused-by-covid-19 live-updates.html 111. Roberton T, Carter ED, Chou VB. Early estimates of the indirect 95. Rodgers TJ. Do lockdowns save many lives? In most places, the data effects of the COVID-19 pandemic on maternal and child mortality say no. Wall Street Journal. April 26, 2020. Accessed May 26, in low-income and middle-income countries: a modelling study. 2020. https://www.wsj.com/articles/do-lockdowns-save-many- Lancet Glob Health. 2020. Published online May 12, 2020. lives-is-most-places-the-data-say-no-11587930911 CrossRef 96. Hodgins S. For COVID-19, will the HIC blueprint work in LMICs? 112. Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 Glob Health Sci Pract. 2020;8(2). CrossRef pandemic on routine pediatric vaccine ordering and 97. Mehtar S, Preiser W, Lakhe NA, et al. Limiting the spread of administration-United States, 2020. MMWR Morb Mortal Wkly – COVID-19 in Africa: one size mitigation strategies do not fit all Rep. 2020;69:591 593. CrossRef. Medline countries. Lancet Glob Health. 2020. Published online April 28, 113. Santoshini S. Family planning efforts upended by the coronavirus. 2020. CrossRef Foreign Policy. May 13, 2020. Accessed June 8, 2020. https://

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foreignpolicy.com/2020/05/13/india-family-planning- epidemiological study. Preprint. Posted online March 28, 2020. upended-coronavirus-women-sexual-reproductive-health/ medRxiv. CrossRef 114. Pancevski B. Forgotten pandemic offers contrast to today’s corona- 122. King A. An old TB vaccine finds new life in coronavirus trials. The virus lockdowns. Wall Street Journal. April 24, 2020. Accessed Scientist. May 4, 2020. Accessed May 26, 2020. https://www. May 26, 2020. https://www.wsj.com/articles/forgotten- the-scientist.com/news-opinion/an-old-tb-vaccine-finds-new-life- pandemic-offers-contrast-to-todays-coronavirus-lockdowns- in-coronavirus-trials-67504 11587720625 123. Moyer MW. Could ‘innate immunology’ save us from the corona- ‘ ’ 115. Draulans D. Finally, a virus got me. Scientist who fought Ebola and virus? NY Times. May 1, 2020. Accessed June 8, 2020. https:// HIV reflects on facing death from COVID-19. Science. May 8, www.nytimes.com/2020/05/01/opinion/sunday/coronavirus- 2020. Accessed May 26, 2020. https://www.sciencemag.org/ vaccine-innate-immunity.html news/2020/05/finally-virus-got-me-scientist-who-fought-ebola- and-hiv-reflects-facing-death-covid-19 124. Walker D, Chi YL, Poli F, Chalkidou K. A tool to estimate the net health impact of COVID-19 policies. Center for Global ‘ ’ 116. Harding L. Weird as hell : the Covid-19 patients who have symp- Development blog. May 26, 2020. Accessed June 8, 2020. toms for months. Guardian. May 15, 2020. Accessed May 26, https://www.cgdev.org/blog/tool-estimate-net-health-impact- 2020. https://www.theguardian.com/world/2020/may/15/ covid-19-policies weird-hell-professor-advent-calendar-covid-19-symptoms-paul- garner 125. Barasa E, Mothupi MC, Guleid F, et al. DFID Policy Brief: Rapid Review of Physical Distancing in Africa. Department for 117. Rao A. ‘People are dying at home’: virus fears deter seriously ill International Development. May 15, 2020. from hospitals. Guardian. May 6,2020. Accessed May 26, 2020. https://www.theguardian.com/world/2020/may/06/dying-at- 126. Ott H. 6 months of coronavirus lockdown could mean 31 million home-non-covid-19-hospitals-coronavirus more cases of domestic violence, UN says. CBS News. April 28, 2020. Accessed May 26, 2020. https://www.cbsnews.com/ 118. Hafner K. Fear of Covid-19 leads other patients to decline critical treatment. NY Times. May 25, 2020. Accessed June 8, 2020. news/domestic-violence-additional-31-million-cases-worldwide/ https://www.nytimes.com/2020/05/25/health/coronavirus- 127. Bosman J. Domestic violence calls mount as restrictions linger: ‘no cancer-heart-treatment.html one can leave’. New York Times. May 15, 2020. Accessed May 119. Kendrick M. COVID. ‘with’‘of’ or ‘because of’. Malcolmkendrick. 26, 2020. https://www.nytimes.com/2020/05/15/us/ org blog. April 6, 2020. Accessed May 26, 2020. https://drmal domestic-violence-coronavirus.html colmkendrick.org/2020/04/06/covid-with-of-or-because-of/ 128. Zakaria R. Domestic violence and coronavirus: hell behind closed 120. 5 common sense reasons why the Africa continent is escaping the doors. The Nation. April 2, 2020. Accessed June 8, 2020. https:// worst of the pandemic. Africa Expat Wives Club blog. May 22, www.thenation.com/article/society/domestic-violence- 2020. Accessed June 8, 2020. https://africaexpatwivesclub. coronavirus/ wordpress.com/2020/05/22/5-common-sense-reasons-why- 129. Adam D. The hellish side of handwashing: how coronavirus is af- the-africa-continent-is-escaping-the-worst-of-the-pandemic/ fecting people with OCD. The Guardian. March 29, 2020. 121. Miller A, Reandelar MJ, Fasciglione K, Roumenova V, Li Y, Otazu Accessed May 26, 2020. https://www.theguardian.com/society/ GH. Correlation between universal BCG vaccination policy 2020/mar/13/why-regular-handwashing-can-be-bad-advice- and reduced morbidity and mortality for COVID-19: an for-patients

Peer Reviewed

Received: May 19, 2020; Accepted: May 19, 2020; First published online: June 17, 2020

Cite this article as: Halperin DT. Coping with COVID-19: learning from past pandemics to avoid pitfalls and panic. Glob Health Sci Pract. 2020; 8(2):155-165. https://doi.org/10.9745/GHSP-D-20-00189

© Halperin. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/ 10.9745/GHSP-D-20-00189

Global Health: Science and Practice 2020 | Volume 8 | Number 2 165 VIEWPOINT

Contraception in the Era of COVID-19

Kavita Nanda,a Elena Lebetkin,a Markus J. Steiner,a Irina Yacobson,a Laneta J. Dorflingera

Key Messages The World Health Organization (WHO) recognizes that countries are at different stages of the COVID-19 n In the face of facility service disruptions due to epidemic/transmission scenario: (1) no reported cases, COVID-19, health care providers, particularly in (2) sporadic cases, (3) clusters of cases, or (4) community low- and middle-income countries, should strive to transmission. However, public health measures that maintain continuity of reproductive health care to WHO recommends for all 4 scenarios include social dis- women and girls as an essential service. tancing.3 To ensure continuation of contraceptive access n When in-person encounters are limited, health and services, including counseling and shared decision care providers should adapt the way contraceptive making, a number of adaptations to existing systems are services are provided by using telehealth when- required. In particular, maximizing the use of a “no- ever possible for counseling, shared decision touch” approach to care whenever possible is essential. making, and side effect management, and should make adjustments to provision of contraceptive methods to ensure access. USE TELEHEALTH FOR COUNSELING AND SCREENING lobally, approximately 50% of pregnancies are un- Use various communication methods that do not require Gintended.1 In low- and middle-income countries, in-person contact (SMS, WhatsApp, video calls, or tele- where access to health care may be limited, unintended phone calls) to: pregnancies can have dire consequences ranging from  Counsel new clients requesting contraception and to unsafe abortion to serious pregnancy complications that – screen for medical eligibility.4 6 contribute to maternal and infant mortality.2 As such, contraception is lifesaving and an essential component  Issue new prescriptions and refills for clients who de- of reproductive health care. The ability to access and sire user-controlled contraceptives (e.g., combined continue using contraception improves women’s repro- oral contraceptives, progestin-only pills, contracep- ductive autonomy, reduces unintended pregnancies, tive patches, or vaginal contraceptive rings) if no and profoundly impacts both women’s and family’s contraindications are evident. Send all prescriptions lives, health, empowerment, and well-being, particu- directly to the pharmacy or clinic to limit contacts. larly in times of stress and hardship.  Inform clients who desire long-acting reversible con- As medical systems, clinics, and communities pre- traceptives (LARCs) of service locations where LARCs pare to meet an unprecedented threat causing increased are being provided. demands for the care of people with COVID-19, strate-  Manage and treat contraceptive side effects, if gies to mitigate virus spread and optimize health care possible. resources are evolving and will need to be country speci- fic. Health care providers should strive to ensure conti- nuity of reproductive health care to women and girls in the face of facility service interruption. Even while an- PROVIDE ADDITIONAL COUNSELING AND nual exams and nonurgent appointments are canceled, INFORMATION maintaining access to reproductive health services, includ-  Counsel on fertility awareness methods7 and correct ing provision of contraception, is key to a comprehensive and consistent condom use in case disruptions occur COVID-19 mitigation strategy and to sustaining the in the supply of other contraceptive commodities. successes of high-quality family planning services that con-  Counsel current LARC users on the effectiveness of tribute to lowering maternal mortality and improving extended use beyond the labeled duration, postpon- newborn and child health. ing routine removals.8  a FHI 360, Durham, NC, USA. Educate clients on emergency contraception includ- Correspondence to Kavita Nanda ([email protected]). ing both over-the-counter and prescription options.

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OPTIMIZE HOW CLIENTS ACCESS  Prescribe or dispense user-controlled contra- CONTRACEPTIVE METHODS ceptive methods, including Sayana Press where available, in sufficient quantities to be initiated  Prescribe/dispense multimonth refills to mini- or continued at home by women who are not mize trips to the pharmacy or clinic. Health in- breastfeeding or, if breastfeeding, initiated as surance plans (where existing) should waive soon as one of the lactational amenorrhea time limitations on refills to allow for multi- method criteria expires. Provide method- month dispensing and should consider elimi- specific instructions to delay until the client is nating or decreasing prescription costs. medically eligible per WHO criteria.  Train for and offer self-injection of Sayana Press As the world grapples with the novel COVID- (DMPA-SC), where available, for women de- 9 19 pandemic, we in the public health community siring injectable contraception. must continue to provide guidance and support to  Continue to offer insertion of LARC methods, ensure that all women, men, and adolescents can such as intrauterine devices and contraceptive access safe and affordable contraception and contra- implants, to new users where possible with ad- ceptive services. Adjustments to the way services are equate safety preparations for the procedure. provided are inevitable; however, quality of and ac- Make arrangements to avoid having too many cess to services must be maintained. We believe the clients in the waiting area. This may involve above guidance provides a foundation for continu- scheduling clients individually, having clients ing safe contraceptive service provision that coun- wait outside, and/or ensuring clients maintain tries may adapt to the local context, taking into adequate social distancing precautions while consideration local policies and stage of the epidemic inside. If LARC insertion is unavailable, offer in each country. the client user-controlled methods. This statement has been adapted from the  Limit direct contact with current LARC users to American College of Obstetricians and Gynecolo- situations where removal cannot be delayed or gists (ACOG) COVID-19 FAQs for Obstetrician- when side effects require a physical/pelvic Gynecologists, Gynecology, available at https:// exam or other tests. www.acog.org/clinical-information/physician-faqs/ covid19-faqs-for-ob-gyns-gynecology.  Consider placing clients who desire permanent

contraception on waitlists and offering them Funding: This work is made possible by the generous support of the bridge contraception as operating rooms ramp American people through the United States Agency for International down all but the most urgent surgery. Development (USAID) provided to FHI 360 through Cooperative Agreement AID-OAA-A-15-00045. The content and views expressed  Provide advance prescriptions for emergency by the authors in this publication do not necessarily reflect the views of USAID, the United States Government, or FHI 360. contraception to increase awareness and re- duce barriers to immediate access. Competing interests: None declared.

MAKE CONSIDERATIONS FOR REFERENCES 1. Bearak J, Popinchalk A, Alkema L, Sedgh G. Global, regional, and POSTPARTUM WOMEN subregional trends in unintended pregnancy and its outcomes from Where possible, initiate or continue counseling 1990 to 2014: estimates from a Bayesian hierarchical model. Lancet and access to immediate postpartum contracep- Glob Health. 2018;6(4):e380–389. CrossRef. Medline tion before hospital discharge, particularly as ac- 2. World Bank. Trends in Maternal Mortality 2000 to 2017: Estimates cess to postpartum visits becomes limited. by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division (Vol. 2) (English). Washington, DC:  Provide LARC immediately postpartum for cli- World Bank Group; 2019. Accessed April 1, 2020. http:// ents who desire LARC and are eligible.6,10 documents.worldbank.org/curated/en/793971568908763231/ Trends-in-maternal-mortality-2000-to-2017-Estimates-by-WHO-  Perform permanent contraception procedures UNICEF-UNFPA-World-Bank-Group-and-the-United-Nations- for clients who desire it at the time of cesarean Population-Division delivery and/or after vaginal delivery, if 3. World Health Organization. Critical preparedness, readiness and response actions for COVID-19. Interim guidance. https://www. available. who.int/publications-detail/critical-preparedness-readiness-and-  Counsel on correct use of the lactational amen- response-actions-for-covid-19. Published March 22, 2020. Accessed April 1, 2020. orrhea method. 4. ACOG. Implementing Telehealth in Practice Committee Opinion  Administer DMPA, if the client desires. Number 798. https://www.acog.org/clinical/clinical-guidance/

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committee-opinion/articles/2020/02/implementing-telehealth- 8. Ali M, Bahamondes L, Bent Landoulsi S. Extended effectiveness of the in-practice. Published February 2020. Accessed March 26, etonogestrel-releasing contraceptive implant and the 20 mg 2020. Levonorgestrel-releasing intrauterine system for 2 years beyond U.S. 5. World Health Organization. Telemedicine: opportunities and Food and Drug Administration product labeling. Glob Health Sci – developments in Member States: report on the second global survey on Pract. 2017;5(4):534 539. CrossRef. Medline eHealth. https://www.who.int/goe/publications/goe_telemedicine_ 9. Kennedy CE, Yeh PT, Gaffield ML, Brady M, Narasimhan M. Self- 2010.pdf. Published 2009. Accessed March 26, 2020. administration of injectable contraception: a systematic review and 6. World Health Organization (WHO). Medical Eligibility Criteria for meta-analysis. BMJ Glob Health. 2019;4(2):e001350. CrossRef. Contraceptive Use. 5th ed. Geneva: WHO; 2015. Accessed March Medline 26, 2020. https://www.who.int/reproductivehealth/publications/ 10. American College of Obstetricians and Gynecologists. Immediate family_planning/MEC-5/en/ postpartum long-acting reversible contraception. Committee 7. Peragallo Urrutia R, Polis CB, Jensen ET, Greene ME, Kennedy E, Opinion Number 670. Obstet Gynecol. 2016;128:e32–37. Stanford JB. Effectiveness of fertility awareness-based methods for Accessed March 26, 2020. https://www.acog.org/clinical/ pregnancy prevention: a systematic review. 2018;132(3):591–604. clinical-guidance/committee-opinion/articles/2016/08/ CrossRef. Medline immediate-postpartum-long-acting-reversible-contraception

Peer Reviewed

Received: March 27, 2019; Accepted: April 3, 2020; First published online: April 20, 2020

Cite this article as: Nanda K, Lebetkin E, Steiner MJ, Yacobson I, Dorflinger LJ. Contraception in the era of COVID-19. Glob Health Sci Pract. 2020; 8(2):166-168. https://doi.org/10.9745/GHSP-D-20-00119

© Nanda et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https:// doi.org/10.9745/GHSP-D-20-00119

Global Health: Science and Practice 2020 | Volume 8 | Number 2 168 VIEWPOINT

Doing Things Differently: What It Would Take to Ensure Continued Access to Contraception During COVID-19

Michelle Weinberger,a Brendan Hayes,b Julia White,c John Skibiakc

Key Messages approaches such as minimizing family planning client- provider contact through use of telehealth and integra- n COVID-19 may fundamentally change women’s tion into other essential services (same-day postpartum contraceptive use, thus altering the range of family planning). They also consider extended use of supplies that will be required in the near term. LARCs, options for method switching, and changing dis- Policy makers will need to consider country pensing guidelines in the event disruptions are encoun- realities and explore service delivery adaptations tered. Many of the suggestions in their piece have also to meet these changing needs. Existing data can been echoed elsewhere.8–12 quantify potential shift in contraceptive use to help COVID-19 is fundamentally changing the contracep- inform decisions. tive landscape, and by extension, the ability of national n Donors, policy makers, and program planners programs to meet women’s immediate needs for contra- may need to revisit supply plans and the use of ception. The future for which we have been planning financing to ensure that contraception is and procuring will not be, in all likelihood, the reality effectively sustained. we see before us in the coming 12–18 months. It is a mis- take, therefore, to call for supply chains to continue feeding programs with a mix of supplies that they may ince the start of the coronavirus disease (COVID-19) no longer be capable of delivering. COVID-19 is raising Spandemic, the family planning community has focused their attention on mitigating the devastating a host of important questions about the relationship be- consequences of failing to meet women’s needs for con- tween product and program. In these unprecedented traception. Recent estimates by the Guttmacher Institute times, we must rethink the ways we link products and ’ suggest that with even just a 10% decline in use of short- programs to ensure continuity in women s access to term and long-acting reversible contraceptives (LARC) contraception. across 132 low- and middle-income countries, unmet To add context to these policy discussions, we have need for contraception would increase by 48.6 million attempted to quantify potential shifts in contraceptive women and lead to 15 million additional unintended use that could result from some of the mitigation strate- pregnancies.1 That risk grows each day as reports come gies we have outlined. We focus on the mitigation to light of clinic closures, the reduced mobile outreach strategies most likely to reflect the availability of contra- services2,3 and declines in the number of clients attend- ceptive options under COVID-19 to highlight the impli- ing even open clinics.4 cations of such changes. To ensure women’s access to a full range of methods as well as removal services, we have seen calls from WHAT MIGHT BE IN STORE FOR across the RH community to safeguard the integrity of CONTRACEPTIVE USERS? existing service delivery systems and the supply chains 5,6 The combination of stay-at-home orders, overwhelmed that support them. These calls are critical and they health care systems, and simply fear of contagion will are welcome. But in environments where these systems likely increase the demand for self-care, defined by the face pressure or cease to function altogether, different World Health Organization as13: solutions are being proposed, such as those made by Nanda et al. in this issue of GHSP.7 They outline The ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a health care a Avenir Health, Washington, DC, USA. provider. b Global Financing Facility, Washington, DC, USA. c Reproductive Health Supplies Coalition, Brussels, Belgium. For contraception, self-care methods include contracep- Correspondence to Michelle Weinberger ([email protected]). tive pills, condoms, patches, rings, emergency contraception,

Global Health: Science and Practice 2020 | Volume 8 | Number 2 169 What It Would Take to Ensure Contraceptive Access During COVID-19 www.ghspjournal.org

Standard Days Method, and potentially self- mitigating the disruption of services caused by injection of subcutaneous depot medroxyproges- COVID-19 might play out in different countries. terone acetate (DMPA-SC). At the same time, there To do this, we created 2 scenarios (Table), each of may be decreased demand for products that require which estimates the potential for method switch- face-to-face contact with a health care provider ing under different levels of COVID-19 related ser- or may be more difficult to obtain, including vice disruption (Supplement includes detailed intrauterine devices, implants, and provider- assumptions). These scenarios assume that all cur- administered injections. These changes would rent users of a modern family planning method run counter to recent trends in contraceptive use would continue to contracept with some degree and public sector procurement. For example, in of method switching. Some women may instead 2018, two-thirds of spending in the public discontinue use in the short run. These scenarios sector family planning market was on implants are not meant to suggest what we think will or 14 Each country’s (US$88 million) and injectables (US$65 million). should happen but rather to provide a starting response will vary Each country is facing COVID-19 from a differ- point for discussions by quantifying the program- depending on ent starting place: different method mixes among matic implications of these policy changes and of how the COVID-19 its current users, differing roles of the public and the choices women may make about what meth- pandemic unfolds private sectors, different levels of stock on hand, ods to use. and different supply chain barriers. And each Although individual women may make similar and what choices country’s response will vary depending on how choices with respect to self-care methods, the ag- women make the pandemic unfolds and what choices women gregate changes in method use, procurement about their make about their continued contraceptive use. needs, and cost would differ greatly among coun- continued We used data from the 2019 Commodity Gap tries. Figure 1 compares changes in method mix in contraceptive use. Analysis15 to simulate how different strategies for Kenya and Nigeria under the 2 scenarios.

TABLE. Summary of Assumptions Used for COVID-19 Disruption Scenariosa

What We Assumed Would Happen With What We Assumed Would Happen With Current Contraceptive Method Used Minimal Disruption to Services High Disruption to Services

LARC  Half of women due for removal would  Nearly all women due for removal would continue to use their method beyond the continue to use their method beyond the labeled duration. labeled duration.  For the remaining, half of replacement  For the rest, replacement use would use would still be LARC, with the rest mostly consist of self-care methods. distributed across injectables and other self-care methods.

Injectable (not self-administered)  Half of women would continue to access  Only a small share of women would their reinjections, with some women continue to access reinjections, with shifting to self-injection. some women switching to self-injection.  Remaining users would switch to other  Remaining users would switch to other self-care methods. self-care methods.

Pill  The vast majority of pill users would  The vast majority of pill users would continue to use pills. continue to use pills.  Users may be given advanced provision  Users may be given advanced provision of 6 or 12 cycles to limit their need to of 6 or 12 cycles to limit their need to return. return.

Condom  The vast majority of condom users would  The vast majority of condom users would continue to use condoms. continue to use condoms.  A small share would switch to other self-  A small share would switch to other self- care methods. care methods.

Abbreviations: LARC, long-acting reversible contraception. a See Supplement for detailed assumptions.

Global Health: Science and Practice 2020 | Volume 8 | Number 2 170 What It Would Take to Ensure Contraceptive Access During COVID-19 www.ghspjournal.org

FIGURE 1. Potential Short-Term Changes in Contraceptive Method Mix During COVID-19 Disruptions in Kenya and Nigeria

Abbreviations: IUD, intrauterine device; LAPM, long-acting and permanent method.

In Kenya, around 40% of women are already example, disruptions in condom supplies or price using a long-acting or permanent method, with increases could have a large impact on contracep- most using implants. Because implant use in tive use in the country. Kenya has increased in recent years, only a small share of users would be due for implant removal/ WHAT COULD THESE CHANGES replacement in the coming months. Furthermore, MEAN FOR SUPPLY NEEDS? based on evidence that many LARC methods can 16,17 The changes described would also have substantial safely be used beyond their labeled duration, implications for the supplies these countries will it is reasonable to assume that many users with a need in the short term. In both scenarios pre- scheduled method replacement this year could sented, we estimate a potential surge in demand remain protected from unintended pregnancy for self-care contraceptive methods. Although the without an additional service during COVID-19 particular methods available and desirable will ul- disruptions should they desire to continue using timately determine what is used, in our scenarios, their method. Of course, when women do require much of the new demand for self-care methods a removal, efforts should be made to ensure safe comes from contraceptive pills. If in addition to access to services. the method switching described, advanced provi- The largest segment of users in Kenya are in- sion of methods is implemented, women would jectable users—making up more than 45% of all receive most of these commodities at once (i.e., modern contraceptive users. These women are front-loading distribution). With this combination likely to find themselves at greatest risk since con- in Kenya, pills dispensed could surge to between tinued use requires regular interaction with a 4 times to 9 times the current levels over the com- health care provider. As disruptions increase, we ing 6 months, and in Nigeria the surge could be assume that more of these women will switch around half of these levels (Figure 2). to self-care methods, likely contraceptive pills, Another potential complication in satisfying which offer similar protection to their current an increased demand from women switching to method of choice. pills would be the type of pill best suited to serve We can contrast this picture with Nigeria, this “replacement” role. Certain institutions, where use of implants is much lower and use of such as the Royal College of Obstetricians and condoms is higher. Although we also project Gynecologists, have recommended the use of increases in pill use in Nigeria, the magnitude progesterone-only pills (POPs) or “mini-pills” as of that increase is smaller. The overall high reli- bridging methods because they have no contrain- ance on short-term methods in Nigeria means dications for high blood pressure—in contrast that more women are potentially susceptible with combined oral contraceptives—and thus do to COVID-19 disruptions of those methods. For not require screening and are likely suitable for

Global Health: Science and Practice 2020 | Volume 8 | Number 2 171 What It Would Take to Ensure Contraceptive Access During COVID-19 www.ghspjournal.org

FIGURE 2. Cumulative Number of Pills Dispensed Over 6 months in Kenya and Nigeria Under Different COVID-19 Disruption Scenarios, April to September 2020

Abbreviations: COC, combined oral contraceptive pill; POP, progesterone-only pill.

injectable users who are already receiving a provider-administered injectables offset by in- progesterone-only product.10 creased consumption of self-care methods as As we look to a As we look to a likely future where self-care women seek alternatives that can be accessed future where self- methods fill gaps left by contractions in current with little or no face-to-face contact with service care methods may service delivery options, we must also raise a criti- providers. ’ fill gaps left by cal concern around equity. Current data from the Each country s response will differ as policy contractions in Commodity Gap Analysis reveal that self-care makers weigh the options before them, consider current service methods are already accessed disproportionately the realities of what supplies they already have — delivery options, from the private sector a disparity that may be- on hand and what can be accessed in the near we must also raise come even more stark if public sector providers term, and observe the response from women as find themselves overwhelmed in responding to they find ways to continue to access contracep- a critical concern COVID-19. This situation could mean that women tion. We outline some key challenges and oppor- around equity. who had previously accessed free or subsidized tunities that should be considered regarding services through the public sector now find them- products and programs and clients. selves struggling to pay out-of-pocket. The burden may be multiplied by advanced provision recom- Challenges and Opportunities Ensuring mendations, or perhaps even more realistically, Product Availability by the higher cost of revisits by women unable to Strategies to mitigate the impacts of COVID-19 ’ purchase multiple months worth of supplies. can only be successful if there are supplies avail- These changes may coincide with broader eco- able to do so. Unpredictability and potentially rap- nomic disruptions in household income that limit id changes in demand will be challenging for ’ women s ability to pay. As we think about strate- centralized supply chains to respond to, especially gies to ensure continued access to contraception, as many of these changes run counter to recent we cannot forget this important factor. Potential trends. In the years leading up to the crisis, public mitigation options are discussed later, including fi- sector procurement of pills declined to only 7% of nancing approaches that can help ensure equita- couple-years of protection shipped in the public ble access. These challenges are also explored sector market in 2018.14 Public procurement of 18 further by Remme et al. POP remains low,19 so stocks may be limited Near-term in countries. In addition, there are few World approaches that Health Organization prequalified pill manufac- allow for flexibility HOW DO WE ENSURE THAT turers, especially for POPs.20 Continued sharing and opportunism COMMODITIES ARE AVAILABLE AND of accurate family planning supply data through in responding to ACCESSIBLE TO WOMEN? existing channels with donors and manufacturers the ever-evolving Although they are only illustrative, these 2 coun- will be important, especially as we look to long- supply chain try scenarios in Kenya and Nigeria point to the po- term supply needs.21 landscape are tential impact of changes that may occur in the Near-term approaches that allow for flexibility needed. short term: decreased consumption of LARCs and and opportunism in responding to the ever-

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evolving landscape are needed. The need for in- require effective communication efforts. Social and creased procurement of self-care methods could behavior change messages can reinforce help in- prompt countries to engage with a wider set of ge- form women about safe mitigation strategies, and neric manufacturers if quality can be assured. address concerns over accessing services or switch- Countries could also look to leverage existing pri- ing methods.23 vate, nongovernmental organizations and social And of course, public sector service delivery marketing supply chains that work beyond the will still play an important role, although that public sector, especially in contexts where these role may change. Using service delivery models Using service supply chains are already bringing large volumes that bring services closer to women and girls will delivery models of self-care methods into a country. be particularly important in light of mobility that bring services Further, for countries and regions with domes- restrictions and concerns about interacting with closer to women tic manufacturing, using these companies, if health facilities. Community health workers, mo- and girls will be quality can be assured, may help reduce chal- bile outreach teams, and partnerships with small important in light lenges with shipping and distribution of supplies. private health care providers could distribute free of mobility Member organizations of the Reproductive Health or subsidized products with more limited face-to- restrictions. Supply Coalition’s ForoLAC (The Latin American face contact. and Caribbean Forum) are already working in Latin America to assemble a regional inventory of THE WAY AHEAD contraceptive manufacturers; similar initiatives in While focusing on short-term solutions to ensure other regions could reduce the uncertainty of se- accessibility during this global pandemic, we must “ curing contraceptives manufactured closer to also keep a focus on the long term. Many of the ” home. changes described will likely be temporary. So, as In addition, donors and partners may need to circumstances change and clinical services become explore opportunities for ensuring that actors more available, systems and supply chains must be across the supply chain have access to the working in place to ensure that women can once again ac- capital needed to keep these products moving. The cess the delivery and removal services not avail- likely temporary nature of these shift may bring able during COVID-19. special financing considerations. We are entering a disruptive phase for essen- tial health services—hopefully a comparatively Challenges and Opportunities for Programs short-lived phase—but one that could dramatical- and Clients ly change both the content of national family Access to self-care methods are likely to come planning programs and the ability of those pro- through private sector channels. These channels grams to meet client needs. In the short term, it is It is important to are well-placed to be nimble and often comprise important to review procurement plans and pro- review large networks of pharmacies and shops that allow grams developed before physical distancing to procurement for easy access to self-care methods. However, this identify any mismatch with current reality and ex- plans and also presents challenges to ensure both equity and plore ways to meet current needs. Now more than programs quality. Countries could explore strategies such as ever, we must bridge the often-siloed discussions developed before strategic purchasing, vouchers, and other financial about product and program to minimize the po- physical support mechanisms to ensure that changes do tentially devastating consequences of COVID-19 distancing to not bring undue burdens, especially for the most on women and girls around the world. identify any vulnerable. Channeling subsidies directly to users The analysis presented in this article provides a mismatch with could also support the development of more resil- first look into quantifying potential shifts in con- current reality and ient and client centered contraceptive markets.22 traceptive needs that could result from different explore ways to We should also remember that women need service disruptions and mitigation strategies. An meet current more than just products. Telehealth and m-health Excel-based tool, Modeling the Impact of COVID- needs. services can play an important role in informing 19 on Reproductive Health Options (MICRO), has women’s choices over what contraceptives to use been developed that allows countries to replicate and answering any questions they may have. Where and expand the types of results shown here for appropriate and feasible, countries may support Kenya and Nigeria. The tool integrates data from use of the Standard Days Method, especially where the Reproductive Health Supplies Visualizer24 on the need for a physical product can be eliminated public sector shipments in recent years to contrast through phone apps. These changes will likely potential changes to recent trends. The model

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includes 2 scenarios aligned to results presented June 5, 2020. https://www.fsrh.org/documents/fsrh-ceu-clinical- here; users can change the assumptions to explore advice-to-support-provision-of-effective/ their own custom mitigation scenarios. In addition, 11. Royal College of Obstetricians and Gynecologists. FSRH CEU recommendation on extended use of the etonogestrel implant and through the Global Family Planning Visibility and 52mg levonorgestrel-releasing intrauterine system during COVID 25 Analytics Network work is underway to assess restrictions. Published online March 20, 2020. Accessed June 5, risks from a supply chain perspective. We can only 2020. https://www.fsrh.org/documents/fsrh-ceu- hope to mitigate the potentially devastating conse- recommendation-on-extended-use-of-the-etonogestrel/ quences of this global pandemic on women’scon- 12. Reproductive Health Access Project. Contraception in the time of COVID-19. Published online March 24, 2020. Accessed June 5, traceptive choices if we focus on using data and 2020. https://www.reproductiveaccess.org/resource/ collaborating to ensure that products and programs contraception-covid/ are moving together. 13. World Health Organization (WHO). WHO Consolidated Guideline on Self-Care Interventions for Health: Sexual and Reproductive Health and Rights. WHO; 2019. Accessed June 5, 2020. https:// Competing interests: None declared. www.who.int/reproductivehealth/publications/self-care- interventions/en/ 14. Clinton Health Access Initiative (CHAI); Reproductive Health Supplies REFERENCES Coalition (RHSC). 2019 Family Planning Market Report. CHAI, 1. Riley T, Sully E, Ahmed Z, Biddlecom A. Estimates of the potential RHSC; 2019. Accessed June 9, 2020. https://www.rhsupplies.org/ impact of the COVID-19 pandemic on sexual and reproductive uploads/tx_rhscpublications/Family-Planning-Market-Report.pdf health in low- and middle-income countries. Int Perspect Sex 15. Reproductive Health Supplies Coalition (RHSC). Commodity Gap Reprod Health. 2020;46:73–76. Accessed June 5, 2020. https:// Analysis: 2019. RHSC; 2019. Accessed June 5, 2020. https:// www.guttmacher.org/journals/ipsrh/2020/04/estimates- www.rhsupplies.org/cga/ potential-impact-covid-19-pandemic-sexual-and-reproductive- health 16. McNicholas C, Maddipati R, Zhao Q, Swor E, Peipert J. Use of the etonogestrel implant and levonorgestrel intrauterine device beyond 2. International Planned Parenthood Federation. COVID-19 pandemic the U.S. Food and Drug Administration–approved duration. Obstet cuts access to sexual and reproductive healthcare for women around Gynecol. 2015;125(3):599–604. CrossRef. Medline the world. News release. Published online April 9, 2020. Accessed April 30, 2020. https://www.ippf.org/news/covid-19-pandemic- 17. Ali M, Akin A, Bahamondes L, et al. Extended use up to 5 years of the cuts-access-sexual-and-reproductive-healthcare-women-around- etonogestrel-releasing subdermal contraceptive implant: comparison world to levonorgestrel-releasing subdermal implant. Hum Reprod. 2016;31(11): 2491–2498. CrossRef. Medline 3. Marie Stopes International. Stories from the frontline: in the shadow of the COVID-19 pandemic. Accessed April 30, 2020. 18. Remme M, Narasimhan M, Wilson D, et al. Self care interventions for https://www.mariestopes.org/covid-19/stories-from-the- sexual and reproductive health and rights: costs, benefits, and fi- frontline/ nancing. BMJ. 2019;365:l1228. CrossRef. Medline 4. Ogbondeminu FO. Young people’s reproductive health needs don’t 19. Reproductive Health Interchange. United Nations Population Fund. pause for pandemics: replicable learnings for A360 Nigeria’s Accessed April 21, 2020. https://www.unfpaprocurement.org/rhi- COVID-19 response. Published online April 22, 2020. Accessed home June 5, 2020. https://a360learninghub.org/a360-nigeria- 20. Prequalified list of medicines/finished pharmaceutical products. covid19-response/ World Health Organization. Accessed April 21, 2020. https:// 5. FP2020. Access to contraception is critical in COVID-19 response. extranet.who.int/prequal/content/prequalified-lists/medicines News release. Published online April 2, 2020. Accessed June 5, 21. Reproductive Health Supply Coalition. Joint statement on the 2020. https://www.familyplanning2020.org/news/access- importance of continued family planning data sharing and contraception-critical-covid-19-response collaboration. Published April 20, 2020. Accessed June 9, 2020. 6. World Health Organization (WHO). Maintaining Essential Health https://www.rhsupplies.org/fileadmin/uploads/rhsc/Uploads/ Services: Operational Guidance for the Covid-19 Context.WHO; Other/Joint_Statement_on_the_Importance_of_Continued_Family_ 2020. Accessed June 5, 2020. https://www.who.int/publications/ Planning_Data_Sharing_and_Collaboration.pdf i/item/covid-19-operational-guidance-for-maintaining-essential- 22. Impact for Health. Access to SRH care: new delivery models & health-services-during-an-outbreak radically new financing. Published May 7, 2020. Accessed June 5, 7. Nanda K, Lebetkin E, Steiner MJ, Yacobson I, Dorflinger LJ. 2020. https://impactforhealth.com/access-to-srh-care/ Contraception in the era of COVID-19. Glob Health Sci Pract. 23. Breakthrough ACTION. Guidance on social and behavior change 2020;8(2). CrossRef. Medline for family planning during COVID-19. Published online April 14, 8. FIGO Committee for Contraception and Family Planning. COVID-19 2020. Accessed June 5, 2020. https://breakthroughactionand contraception and family planning. Published April 13, 2020. research.org/wp-content/uploads/2020/03/Guidance-on-SBC- Accessed April 28, 2020. https://www.figo.org/covid-19- for-FP-During-COVID19.pdf contraception-family-planning 24. Reproductive Health Supplies Visualizer. Reproductive Health Supply 9. World Health Organization. Contraception/family planning and Coalition. 2020. Accessed June 9, 2020. https://www.rhsupplies. COVID-19. Published April 6, 2020. Accessed April 14, 2020. org/activities-resources/tools/reproductive-health-supplies- https://www.who.int/news-room/q-a-detail/contraception-family- visualizer-rh-viz/ planning-and-covid-19 25. Global Family Planning Visibility and Analytics Network. 10. Royal College of Obstetricians and Gynecologists. FSRH CEU clinical Reproductive Health Supply Coalition. 2020. Accessed June 9, advice to support provision of effective contraception during the 2020. https://www.rhsupplies.org/activities-resources/tools/ COVID-19 outbreak. Published online March 20, 2020. Accessed global-fp-van/

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Peer Reviewed

Received: May 3, 2019; Accepted: June 2, 2020; First published online: June 19, 2020

Cite this article as: Weinberger M, Hayes B, White J, Skibiak J. Doing things differently: what it would take to ensure continued access to contraception during COVID-19. Glob Health Sci Pract. 2020;8(2):169-175. https://doi.org/10.9745/GHSP-D-20-00171

© Weinberger et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-20-00171

Global Health: Science and Practice 2020 | Volume 8 | Number 2 175 VIEWPOINT

Multimonth Dispensing of Antiretroviral Therapy Protects the Most Vulnerable From 2 Pandemics at Once

Ariana Moriah Traub,a Temitayo Ifafore-Calfee,b Benjamin Ryan Phelpsb

Key Messages increasing the spread of SARS-CoV-2 and other trans- missible diseases. Thus, policy makers—including the n Multimonth dispensing, which provides patients U.S. President’s Emergency Plan for AIDS Relief—are with several months of antiretroviral therapy, encouraging countries to provide PLHIV with a multi- benefits HIV patients by decreasing the number month supply of ART as a key strategy to safeguard of required clinic visits, improving retention, and PLHIV and health care workers involved in providing improving viral suppression. HIV services.4 n With the increased spread of severe acute respiratory syndrome coronavirus 2, we encourage governments, ministries of health, and MULTIMONTH ART DISPENSING health care facilities to implement multimonth MITIGATES RISK OF HIV AND COVID-19 dispensing for patients with HIV who are stable to Multimonth dispensing (MMD) is an aspect of differen- reduce clinic visits and safeguard both health care tiated service delivery that provides patients with either workers and patients from coronavirus disease 3 or 6 months of medication and eliminates the need for 2019. monthly clinic and/or community facility visits. From the patient’s perspective, MMD has already been shown to reduce the cost of travel, reduce patient burden, and ince the emergence of the severe acute respiratory limit the hours of work or school lost.5,6 Importantly, Ssyndrome coronavirus 2 (SARS-CoV-2) in MMD improves adherence and viral suppression.5,7 In December 2019, the virus has been identified in more the context of the COVID-19 pandemic, this viral sup- than 183 countries.1 Its rapid spread is of major concern pression strengthens the immune system and likely miti- 8 for those living in low- and middle-income countries gates the risk of severe COVID-19. MMD, essential to and specifically people living with HIV (PLHIV). With caring for PLHIV, is arguably even more critical during the dearth of studies on HIV-coronavirus disease the COVID-19 pandemic. 2019 (COVID-19) coinfections, countries have no clear Currently, only 21 countries have formal 6-month evidence on specific risks for PLHIV.2,3 However, as dispensing policies. Two countries allow clinicians to with other infectious diseases, it is expected that PLHIV provide 6-month supply when they deem appropriate, who are not virally suppressed and/or on antiretroviral and 8 countries have a 3-month dispensing policy in therapy (ART) might be at an increased risk of COVID- place. South Africa, the country with the largest number 19 infection, severe disease, and poor health out- of PLHIV, only has a 2-month dispensing policy in place. comes.2,3 Thus, every precaution must be taken to avoid To mitigate the damage caused by SARS-CoV-2 HIV-COVID-19 coinfection and keep the number of while protecting the health of PLHIV, we encourage COVID-19 cases at a minimum in countries with high countries to rapidly implement 3-month if not 6-month proportions of PLHIV. dispensing. As a key strategy to safeguard patients and To minimize the spread of COVID-19, PLHIV are health care workers providing HIV services, MMD also encouraged to follow public health guidelines to limit reduces clinic visits, improves viral suppression, encourages social distancing, and potentially saves in-person interactions and general mitigation recom- patients from the dual threat of SARS-CoV-2 and HIV. mendations, including social distancing and good hand As SARS-CoV-2 spreads, patient caseloads are likely to hygiene. Refilling lifesaving antiretroviral drugs requires increase across low- and middle-income countries interpersonal interaction and brings the potential of where HIV burden is high and millions of people are sta- ble on effective treatment. Implementing MMD quickly a Sustaining Technical and Analytic Resources, United States Agency for International Development (USAID), Washington, DC, USA. will protect the time and health of existing health care b Office of HIV/AIDS, USAID, Washington, DC, USA. professionals and ready our health systems for imminent Correspondence to Ariana Moriah Traub ([email protected]). threats as well as any that may follow.

Global Health: Science and Practice 2020 | Volume 8 | Number 2 176 Multimonth Antiretroviral Therapy Dispensing Protects Against 2 Pandemics www.ghspjournal.org

Disclaimer: The views expressed in this article are solely the views of the 4. U.S. President’s Emergency Plan for AIDS Relief. PEPFAR’s HIV authors and do not necessarily reflect the views of participating federal Response in the Context of Coronavirus Disease 2019 (COVID-19). agencies, including the United States Agency for International https://www.state.gov/pepfar/coronavirus/. Published March 25, Development or the United States Government. 2020. Accessed April 9, 2020. 5. Faturiyele IO, Appolinare T, Ngorima-Mabhena N, et al. REFERENCES Outcomes of community-based differentiated models of multi- 1. Dong E, Du H, Gardner L. An interactive web-based dashboard to month dispensing of antiretroviral medication among stable HIV- track COVID-19 in real time. Lancet Infect Dis. 2020. CrossRef. infected patients in Lesotho: a cluster randomised non-inferiority BMC Public Health Medline trial protocol. . 2018;18(1):1069. CrossRef. Medline 2. Centers for Disease Control and Prevention. What to Know About HIV and COVID-19. https://www.cdc.gov/coronavirus/2019- 6. Babigumira JB, Castelnuevo B, Stergachis A, et al. Cost effectiveness of ncov/need-extra-precautions/hiv.html?CDC_AA_refVal=https%3A%2F a pharmacy-only refill program in a large urban HIV/AIDS clinic in PloS One %2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fspecific-groups% Uganda. . 2011;6(3):e18193. CrossRef. Medline 2Fhiv.html. Updated March 18, 2020. Accessed March 31, 2020. 7. Prust ML, Banda CK, Nyirenda R, et al. Multi-month prescriptions, fast- 3. U.S. Department of Health and Human Services. Interim track refills, and community ART groups: results from a process evalu- Guidance for COVID-19 and Persons with HIV. https://aidsinfo. ation in Malawi on using differentiated models of care to achieve na- J Int AIDS Soc nih.gov/guidelines/html/8/covid-19-and-persons-with-hiv– tional HIV treatment goals. . 2017;20(Suppl 4):21650. interim-guidance-/554/interim-guidance-for-covid-19-and- CrossRef. Medline persons-with-hiv. Updated April 21, 2020. Accessed March 31, 8. Deeks SG, Overbaugh J, Phillips A, Buchbinder S. HIV infection. Nat 2020. Rev Dis Primers. 2015;1:15035. CrossRef. Medline

Peer Reviewed

Received: April 16, 2020; Accepted: May 6, 2020

Cite this article as: Traub AM, Ifafore-Calfee T, Phelps B. Multimonth dispensing of antiretroviral therapy protects the most vulnerable from 2 pandemics at once. Glob Health Sci Pract. 2020;8(2):176-177. https://doi.org/10.9745/GHSP-D-20-00160

© Traub et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https:// doi.org/10.9745/GHSP-D-20-00160

Global Health: Science and Practice 2020 | Volume 8 | Number 2 177 VIEWPOINT

Ebola: A Hyperinflated Emergency

Victor K. Barbieroa

Key Messages However, EVD is an epizootic infection with periodic human exposure and transmission. Since its emergence n Ebola virus disease outbreaks merit global in 1976; the virus remains an uncomfortable human concern, but worry and response can be pathogen. It kills too fast, kills too many, and is not easily hyperinflated. transmitted; thus, human outbreaks are limited, and its n Ebola has killed about 15,266 people globally pandemic potential is moderate to low. It has not yet since 1976. Most recently, 2,267 people have achieved equilibrium with its human host as it apparent- died in the Democratic Republic of the Congo ly has with its bat host. Furthermore, EVD’s 40%– (DRC). However, these numbers pale in 50% CFR in humans may be considered evolutionarily comparison to the under-5 deaths globally and in unsound in many respects for a successful human the DRC over the same period. pathogen. n Global child survival should be considered a But, the real issue concerning EVD is disease sensa- public health emergency of international concern. tionalism. This can be characterized as an unfounded n Governments, donors, and multilateral perception of a global emergency, not necessarily an- organizations should significantly ramp up chored in the epidemiology, pandemic potential, and to- support for child survival interventions, including tal mortality of a pathogen. Rather, it appears the sustained system strengthening. classification of a global emergency is based more on the political ramifications, the newsworthiness of the he 2019–2020 Ebola virus disease (EVD) outbreak in disease de jour, and yes, financial aspects and funding Tthe Democratic Republic of the Congo (DRC) was a streams of a declared emergency for an emerging tragic and significant threat to thousands of people in the and/or reemerging infection. Tragically, more than DRC and West Africa in general. As of March 25, 2020, 11,000 died of EVD in Guinea, Liberia, and Sierra an estimated 3,462 people in the DRC have been Leone. However, it should be recognized that far more infected and an estimated 2,267 people have died from individuals (especially children under 5 years old) died this terrible virus. Since EVD was first characterized in since 1976 in these countries from preventable and 1976, there have been 38 country-specific outbreaks, in- treatable but less exotic infections. Should there not be cluding the outbreak in the DRC. The total estimated a “moral claim” by the world’s children on emergency EVD deaths from 1976 to 2020 is 15,266. The median resources as well? number of deaths for all 38 outbreaks is 29 with a range In 2014, the Obama administration submitted an of 0 to 4,809 (Table 1).1,2 emergency funding request, and in 2015, Congress au- The EVD case fatality rate (CFR) can be 0 or reach thorized an appropriation of approximately US$5.4 bil- 100%, depending on the scope and location of the out- lion in an omnibus emergency bill to combat EVD break (e.g., 2011 Uganda [1 case 1 death], Senegal spread, protect America from an EVD outbreak, and sup- 2014 [1 case, 0 deaths]). Although there are 4 different 5 types of Ebola virus,3 generally speaking, the EVD port the development of an EVD vaccine. Notably, this CFR averages about 50%.4 The 2015 outbreak in appropriation exceeded the total 2015 authorization of Guinea, Liberia, and Sierra Leone infected an estimated US$3.13 billion for all U.S. government assistance for 28,610 people and killed 11,308 with a CFR of approxi- maternal, child, reproductive health, malaria, nutrition, 6 mately 40%. Without question, EVD is an important and and neglected tropical diseases by US$227 million. Did daunting public health issue for Africa and potentially EVD epidemiology and national/global risk justify the for the world. emergency bill investment? Perhaps, perhaps not. Clearly emerging and reemerging infections are im- portant and need to be handled with interventions that a George Washington University Milken Institute of Public Health, Washington, DC, USA. mitigate spread and minimize mortality, coupled with Correspondence to Victor Barbiero ([email protected]). adequate and sustained epidemic preparedness. Indeed,

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TABLE 1. Country-Specific Ebola Virus Disease Outbreak Timeline

Year Country Cases, No. Deaths, No. CFR, %

1976 DRC 318 280 88.1 1976 Sudan 284 151 53.2 1977 DRC 1 1 100.0 1979 Sudan 34 22 64.7 1994 Gabon 52 31 59.6 1994 Ivory Coast 1 0 0.0 1995 DRC 315 254 80.6 1996 Gabon 31 21 67.7 1996 Gabon 60 45 75.0 1996 South Africa 1 1 100.0 2000 Uganda 425 224 52.7 2002 Gabon 65 53 81.5 2002 Congo 59 44 74.6 2003 Congo 143 128 89.5 2003 Congo 35 29 82.9 2004 Sudan 17 7 41.2 2005 Congo 12 10 83.3 2007 DRC 264 187 70.8 2007 Uganda 149 37 24.8 2008 DRC 32 14 43.8 2011 Uganda 1 1 100.0 2012 Uganda 24 17 70.8 2012 Uganda 7 4 57.1 2012 DRC 57 29 50.9 2014 Nigeria 20 8 40.0 2014 Mali 8 6 75.0 2014 Senegal 1 0 0.0 2014 USA 4 1 25.0 2014 UK 1 0 0.0 2014 DRC 69 49 71.0 2014 Spain 1 0 0.0 2015 Italy 1 0 0.0 2014–2016 Guinea 3,811 2,543 66.7 2014–2016 Liberia 10,675 4,809 45.0 2014–2016 Sierra Leone 14,124 3,956 28.0 2017 DRC 8 4 50.0 2018 DRC 54 33 61.1 2018–2020a DRC 3,462 2,267 65.5 Total 1976–2020 34,626 15,266 44.1

Abbreviations: CFR, case fatality rate; DRC, the Democratic Republic of the Congo; UK, United Kingdom. a Until March 4, 2020.

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TABLE 2. Under-5 Deaths in the Democratic Republic of the Congo from 1976–20178a

Year Estimated Level 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 Total Deaths

Low 196,957 200,518 204,337 208,117 211,628 215,118 219,168 222,591 226,628 231,114 235,707 2,371,883 Medium 233,087 235,767 238,287 241,006 243,644 246,468 249,515 252,490 255,711 259,276 263,126 2,718,377 High 275,619 276,160 277,290 278,019 279,506 280,937 282,416 284,257 286,999 289,612 292,898 3,103,713

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Total Deaths Low 240,269 245,357 250,850 256,597 262,380 268,588 275,015 281,307 287,517 292,755 296,860 2,957,495 Medium 267,689 272,359 277,624 283,090 289,076 295,539 302,429 309,281 315,772 321,800 326,733 3,261,392 High 296,555 301,225 306,764 312,320 318,881 326,150 333,311 341,237 348,421 355,187 360,844 3,600,895

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Total Deaths Low 299,906 301,930 302,590 302,362 301,596 300,522 298,587 295,532 291,987 287,351 281,512 3,263,875 Medium 330,528 332,688 333,792 333,850 333,311 332,597 331,277 329,811 328,038 326,465 324,650 3,637,007 High 365,124 368,169 369,844 370,391 370,239 369,727 368,988 368,562 369,274 371,071 373,064 4,064,453

2009 2010 2011 2012 2013 2014 2015 2016 2017 Total Deaths Low 274,783 267,800 259,746 251,199 243,411 234,782 225,454 216,143 206,535 2,179,853 Medium 322,801 320,391 318,265 315,758 313,762 310,711 307,687 303,618 300,265 2,813,258 High 375,987 380,011 383,529 387,635 393,306 399,404 405,716 415,115 422,796 3,563,499

Totals 1976–2017 Total Deaths Low 10,773,106 Medium 12,430,034 High 14,332,560 a As of December 19, 2019.

there have been concrete benefits for managing epidemiological impact when millions of people are future internationally-important outbreaks such at risk from diseases that can be prevented, treated, as better infection prevention techniques and and cured. equipment, improved surveillance methods, bet- It is a sad and tragic fact that from 1976 to ter international response, and a better under- present, approximately 34,600 individuals standing of behavioral determinants and the basic have been infected with EVD and approximate- biology of such viruses and techniques for vaccine ly 15,200 have died from EVD (CFR=44.1%) and therapeutic development. Furthermore, in (Table 1). It is noteworthy that the U.S. Centers for some countries, lessons learned from the severe Disease Control and Prevention predicted that the acute respiratory syndrome and Middle East respi- 2014–2016 West African EVD outbreak could ratory syndrome outbreaks are being applied to the have infected more than 1.4 million people in present COVID-19 pandemic. Liberia and Sierra Leone alone7: Hyperinflated, news-based fear; questionable statistical models; and global emergency statements Extrapolating trends to January 20, 2015, without ad- should not justify disproportionate allocations of ditional interventions or changes in community behav- time and effort on a specific issue of lesser ior (e.g., notable reductions in unsafe burial practices),

Global Health: Science and Practice 2020 | Volume 8 | Number 2 180 Ebola: A Hyperinflated Emergency www.ghspjournal.org

FIGURE. Estimated Cumulative Under-5 Mortality in the Democratic Republic of the Congo Versus Global Ebola Virus Disease Mortality, 1976–2017a,2,8

4,500,000 Global Ebola virus disease mortality Low under-5 mortality estimate Medium under-5 mortality estimate High under-5 mortality estimate 4,000,000

3,500,000

3,000,000

2,500,000

2,000,000

1,500,000

1,000,000 454 352 733 11,427 500,000

0 1976-1986 1987-1997 1998-2008 2009-2017 aNote: Ebola virus disease mortality not to scale.

the model also estimates that Liberia and Sierra Leone on existing and/or potential morbidity and mor- will have approximately 550,000 Ebola cases (1.4 mil- tality on a national, regional, or global scale. As lion when corrected for underreporting). noted, the burden of disease for children under Over the period from 1976 to 2017, in the 5 years old dramatically exceeds the cumulative glob- DRC alone approximately 12.43 million children al morbidity and mortality from EVD. Considering under 5 years old have died, mostly from prevent- measles alone, from January 2019 through able and curable childhood diseases (Table 2)8 November 2019, the United Nations Children’s (Figure).2 This number dwarfs the 15,266 people Fund reported 5,000 measles deaths (90% in chil- who have died from EVD globally over the same dren under 5 years old) in the DRC, with over period. Furthermore, at the global level, annually, 200,000 measles cases.11,12 Globally, measles surged an estimated 5.3 million children under 5 years in 2019 and killed about 140,000 worldwide,13 which old die from preventable and curable causes is about 9.2 times the total number of deaths caused 9 worldwide. Which qualifies as a more urgent by EVD in its 43-year history as a human pathogen. and important global health emergency: global Clearly, great success has been achieved over EVD or global under-5 mortality? the last 25 years in reducing deaths in children un- The term public health emergency of inte- der 5 years old. However, in my view, the “unfin- rnational concern (PHEIC) is defined in the ished agenda for child survival,”14 also qualifies as International Health Regulations (2005) as: a public health emergency that should be of inter- An extraordinary event, which is determined, as national concern. It deserves heightened attention provided in these Regulations: to constitute a pub- by the governments, multilateral and bilateral lic health risk to other States through the interna- donors alike, and should not be marginalized. tional spread of disease; and to potentially require Every day, approximately 14,500 children under The “unfinished a coordinated international response. This defini- 5 years old die, the equivalent of 35 Boeing agenda for child 15 tion implies a situation that: is serious, unusual or 747 plane crashes. Clearly, global child mortality survival,” also unexpected; carries implications for public health fits the World Health Organization’s definition of a qualifies as a ’ beyond the affected State s national border; and “Grade 3” emergency and should be categorized as 10 public health may require immediate international action. 16 such. We need increased and continuous global emergency that The PHEIC definition accurately describes investment in child survival and sustainable should be of an epidemiological emergency. However, it falls health system development.17 The moral claim of international short on quantifying the impact of the emergency the world’s children should no longer be ignored. concern.

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REFERENCES 9. Children: reducing mortality. World Health Organization website. https://www.who.int/news-room/fact-sheets/detail/children- ’ 1. Bean M. Timeline of global Ebola outbreaks, 1976-present. Becker s reducing-mortality. Published September 19, 2019. Hosp Rev. https://www.beckershospitalreview.com/quality/ timeline-of-global-ebola-outbreaks-1976-present.html. Published 10. IHR Procedures concerning public health emergencies of December 4, 2018. Accessed December 20, 2019. international concern (PHEIC). World Health Organization website. Accessed December 20, 2019. https://www.who.int/ihr/ 2. Ebola in the Democratic Republic of the Congo: health emergency procedures/pheic/en/ update. World Health Organization website. Accessed December 11. Beigbeder E. 4,500 children under the age of five have died from 20, 2019. https://www.who.int/emergencies/diseases/ebola/ measles in the Democratic Republic of Congo so far this year. drc-2019 UNICEF website. https://www.unicef.org/press-releases/4500- 3. What is Ebola virus disease? Centers for Disease Control and children-under-age-five-died-measles-democratic-republic-congo- Prevention website. https://www.cdc.gov/vhf/ebola/about.html. so-far-year. Published November 27, 2019. Accessed December Published November 5, 2019. Accessed December 20, 2019. 20, 2019. 4. Ebola virus disease. World Health Organization website. https:// 12. As measles deaths in the Democratic Republic of the Congo top www.who.int/news-room/fact-sheets/detail/ebola-virus-disease. 4,000, UNICEF rushes medical kits to health centers and vaccinates Published February 10, 2020. Accessed February 25, 2020. thousands more children. UNICEF website. https://www.unicef. 5. Kates J, Michaud J, Wexler A, Valentine A. The U.S. Response to org/press-releases/measles-deaths-democratic-republic-congo- Ebola: Status of the FY 2015 Emergency Ebola Appropriation. Menlo top-4000-unicef-rushes-medical-kits-health. Published October 9, Park, CA: Kaiser Family Foundation; 2015. https://www.kff.org/ 2019. Accessed December 20, 2019. global-health-policy/issue-brief/the-u-s-response-to-ebola-status- 13. More than 140,000 die from measles as cases surge worldwide. of-the-fy2015-emergency-ebola-appropriation/. Published World Health Organization website. https://www.who.int/news- December 11, 2015. Accessed December 20, 2019. room/detail/05-12-2019-more-than-140-000-die-from-measles- as-cases-surge-worldwide. Published December 5, 2019. Accessed 6. Kaiser Family Foundation. U.S. Global Health Budget: Overview. December 20, 2019. http://files.kff.org/attachment/Fact-Sheet-Breaking-Down-the-US- Global-Health-Budget-by-Program-Area. Published May 2019. 14. Bryce J, Victora CG, Black RE. 2013. The unfinished agenda in child Accessed December 20, 2019. survival. Lancet. 2013; 382(9897):1049–1059. CrossRef. Medline 7. Meltzer MI, Atkins CY, Santibanez S, et. al. Estimating the future 15. Boeing 747. Wikipedia website. Accessed December 20, 2019. number of cases in the Ebola epidemic–Liberia and Sierra Leone, https://en.wikipedia.org/wiki/Boeing_747 2014–2015. MMWR Suppl. 2014; 63(3): 1–14. Medline 16. Emergencies. World Health Organization website. Accessed 8. United Nations Children’s Fund (UNICEF). Child mortality estimates: December 20, 2019. https://www.who.int/emergencies/crises/ country-specific under-five deaths. UNICEF Global Databases. en/ https://data.unicef.org/topic/child-survival/under-five-mortality/. 17. Barbiero VK. It’s not Ebola ...it’s the systems. Glob Health Sci Pract. Updated September 19, 2019. Accessed December 20, 2019. 2014; 2(4):374–375. CrossRef. Medline

Received: December 26, 2019; Accepted: April 7, 2020; First published online: May 19, 2020

Cite this article as: Barbiero VK. Ebola: a hyperinflated emergency. Glob Health Sci Pract. 2020;8(2):178-182. https://doi.org/10.9745/GHSP-D- 19-00422

© Barbiero. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/ 10.9745/GHSP-D-19-00422

Global Health: Science and Practice 2020 | Volume 8 | Number 2 182 VIEWPOINT

Breaking Specialty Silos: Improving Global Child Health Through Essential Surgical Care

Isaac Wasserman,a,b,c Alexander W. Peters,b,c,d Lina Roa,b,c,e Farhana Amanullah,f Lubna Samadg

Key Messages require focusing on low- and middle-income countries (LMICs),3 where more than 90% of child deaths occur.4 n Despite the large role that children’s surgery plays An estimated 43% of the population of sub-Saharan in reducing morbidity and mortality, global child Africa is aged 15 and younger, and approximately health initiatives have historically focused on 30% of the population in LMICs fall in this age group.5 nonsurgical diseases. Addressing the needs of this underserved communi- n Children’s health care providers and children’s ty requires a coordinated “all hands on deck” approach surgery providers can collaborate to improve between all stakeholders, particularly children’s health children’s health through shared values. care providers, surgeons, and nonphysician clinicians. n Long-term investments in surgical workforce Global efforts addressing children’s health have histori- development must accompany more immediate cally, and to this day, focused their efforts on nonsurgical measures addressing the current surgical burden. diseases (Figure).6,7 n The Lancet Commission on Global Surgery provides a framework to which children’s surgery BURDEN OF CHILDHOOD SURGICAL can harmoniously be integrated. DISEASE n Innovative funding mechanisms may invest to Children and adolescents comprise 1.7 billion of the scale cost-effective operations along with ongoing nearly 5 billion people who lack access to surgical data collection and research. care.8–10 To make matters worse, in some LMICs like The Gambia, estimates predict 85% of children will re- quire surgical care before they are aged 15 years.11 Children’s surgery plays a large role in reducing the morbidity associated with noncommunicable condi- tions, such as inguinal hernias,12,13 injuries, and congen- INTRODUCTION 14 he United Nations’ third Sustainable Development ital anomalies, as well as various infectious disease T “ complications, such as hydrocephalus and blindness Goal (SDG-3) is to ensure healthy lives and pro- 15 mote well-being for all at all ages.”1 In particular, this from trachoma. goal aspires to reduce neonatal mortality to less than Specific, surgical interventions for children have been found to be even more cost-effective than accepted 12 per 1,000 live births and under-5 mortality to less 16–18 than 25 per 1,000.2 SDG-3 also addresses trauma, aspir- adult surgeries, even in low-resource settings. In ing to halve “the number of global deaths and injuries particular, the cost-effectiveness of circumcision has ” been reported to be similar to bed nets for malaria from road traffic accidents by 2020. Access to safe sur- 17 gery and anesthesia will help achieve SDG-3 and will prevention. Additionally, the cost-effectiveness of cleft lip or palate repair, general surgery, hydrocephalus sur- a Icahn School of Medicine at Mount Sinai, New York, NY, USA. gery, and ophthalmic surgery were all similar to that of b Program in Global Surgery and Social Change, Department of Global Health the BCG vaccine for tuberculosis. Finally, the cost- and Social Medicine, Harvard Medical School, Boston, MA, USA. effectiveness of cesarean deliveries and orthopedic sur- c Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA, USA. gery were more favorable than the cost- effectiveness of d Department of Surgery, Weill Cornell Medical College, New York, NY, USA. medical treatment for ischemic heart disease and HIV e Department of Obstetrics & Gynecology, University of Alberta, Edmonton, treatment. Canada. Road traffic injuries alone, for example, account for f The Indus Hospital, Karachi, Pakistan. g more deaths in children aged 5 to 14 years than HIV, tu- Center for Essential Surgical and Acute Care, Indus Health Network, Karachi, 19 Pakistan. berculosis, and malaria combined. However, this bur- Correspondence to Isaac Wasserman ([email protected]). den is not borne uniformly across the world; 95% of all

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FIGURE. United Nations Children’s Fund Budget for Program Funding, 2018–2021a

a US$billion

children killed by road traffic accidents are in attention must be given to preventing, identifying, LMICs.20 Similarly, 80% of all children killed by and treating congenital and noncommunicable fall-related injuries are also in LMICs. Integrating diseases, injuries, and burns if the health of chil- children’s surgical providers into all levels of coor- dren is to be improved in accordance with global dination—from supply chains to public health commitments. policies—is integral to addressing pediatric trau- matic morbidity and mortality. Cardiac, neural tube, and craniofacial anoma- INADEQUATE SURGICAL lies, such as cleft lip and palate, account for at WORKFORCE ’ The gap between least 32 million lost disability adjusted life-years The gap between trained children s surgical provi- trained children’s (DALYs), 57% of which could be averted through ders and the need is vast. Currently, the number of ’ inversely surgical providers childhood surgical interventions.15 Currently, children s surgeons is proportional to a ’ 27 and the need is more than 300,000 newborns die within 4 weeks country s birth rate, meaning the countries that vast. due to congenital anomalies.21 Studies examining are most in need of surgical care for children have the unmet burden of children’s surgical disease the least capacity for delivering this care. This are lacking, but recent attempts to quantify and need is most acute in many African nations, where ’ clarify these numbers have relied on using surgical the density of children s surgeons ranges from ’ million delay and the resulting backlog of cases.22 In a 0.17 children s surgeons per children in ’ study examining burden of congenital anomalies Malawi, to 1.5 children s surgeons per million in 28 in 13 African countries, the average surgical delay Egypt. Compared to a benchmark of 10 chil- ’ was more than 2 years—contributing to nearly dren s surgeons per million children used by 75,000 lost DALYs.23–25 Surgical burden for con- Krishnaswami et al., low-income African nations ’ genital anomalies is likely related to not only sur- have a shortfall of more than 3,000 children s sur- 27 gical workforce, but also population size and birth geons. Equally essential, pediatric anesthesia rate—highlighting the need for collaboration be- faces severe workforce shortages, with specialized tween surgical and obstetric providers with public provider density estimated to be 100 times lower 29 health practitioners. in LMICs than in high-income countries. To ad- Furthermore, this burden is spread among all dress this shortfall, LMICs need not only more an- LMICs, with sub-Saharan Africa and South Asia esthesia providers, but also providers who have sharing a similarly large burden of DALYs averta- specialty training and skills needed to manage pe- ble through children’s surgery.26 Clearly, more diatric anatomy and physiology.

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OVERLAPPING GOALS: PEDIATRIC requires both children’s health care providers and Promoting good AND GLOBAL SURGERY surgery providers to work together and outside of global child health their specialty-specific silos. requires both COMMUNITIES children’shealth The solidarity between children’s health care pro- care providers viders and children’s surgery providers is deeper RECOMMENDATIONS FOR and surgery than merely sharing patient populations and an IMPROVING GLOBAL CHILD HEALTH providers to work overarching goal of improving children’s health. ’ Children’s surgery would be ineffective without Develop the Children s Surgical Workforce together and the children’s health care provider correctly diag- An adequate surgical workforce is indispensable in outside their ’ nosing and referring a child with, for example, a meeting the demand for children s surgical care. specialty-specific congenital anomaly. Moreover, the presurgical As both GICS and the Global Health Task Force silos. preparation and postsurgical care for these patients, have articulated, training a robust global pediatric especially neonates, ideally would involve joint workforce, with a focus on sustainable, ground-up coordination between children’shealthcare improvements, is critical. One such model builds providers and their surgical colleagues. Finally, on the example set by the U.S. National Institutes synergies between humanitarian and health de- of Health-funded Medical Education Partnership 37 velopment exist—preparation for surgical care is Initiative. Between 2010 and 2015, 13 medical an integral part to disaster and emergency pre- schools in 12 sub-Saharan African countries were paredness around the world.30 awarded $130 million to work with a U.S.-based Some progress toward addressing bringing university to increase the schools’ abilities to children’s health care providers and surgery provi- (1) produce more and better-trained doctors, ders closer together has been made. In 2002, the (2) strengthen relevant research, and (3) retain Surgical Advisory Panel of the American Academy graduates. Building on this model, children’s of Pediatrics worked with children’s health care health care providers and children’s surgeon providers to develop referral guidelines, represent- groups can collaborate with local medical schools ing an U.S.-focused example of potential collabora- and governments to support the development of tion.31 The Global Initiative for Children’s Surgery a workforce specific for children’s health care in (GICS), founded in 2016, provides a platform and each country that integrates the provision of both an organized voice for children’ssurgery.GICS medical and surgical care. members—representing surgeons, anesthetists, and A survey of children’s surgeons in Africa dem- nonphysician clinicians—work with stakeholders in onstrated a clear preference for “collaborative LMICs to identify barriers to care and develop professional development” over mission-based di- country-specific plans to improve children’ssurgical rect clinical care.38 The coordination of both care.32,33 In addition, in 2013, the American Board pediatric- and surgery-specific organizations to of Pediatrics convened a Global Health Task improve in-country training opportunities and Force to coordinate the expansion of their “core promote effective recognition and referral path- mission—training assessment, certification, and ways for care is needed. These organizations quality improvement and continuing profession- should work with respective ministries of health, al development”—into the international sphere, academic partners, and other stakeholders to de- helping to train international children’shealth velop local, pediatric-specific postgraduate resi- care providers through their International In- dency training programs. Training Examination.4,34 Although not specific There exists a potential trade-off between the to children’s surgery, the Global Health Workforce timeline necessary to sustainably develop and Alliance (now Network) focused on bringing atten- train a specialized workforce and the immediate tion to human resources for health to augment clinical need today. Working closely with minis- health care capacity.35 tries of health, professional organizations, and Much can be There is much to be gained from further inte- existing referral networks, children’s health care gained from grating children’s surgery into advocacy efforts providers and surgery providers should task shift integrating and the broader global child health agenda. and task share carefully selected components of children’ssurgery Building off the history of collaboration between care to nonspecialty trained providers as a poten- into advocacy children’s surgeons and the American Academy tial, short-term bridge to the development of efforts and the of Pediatrics as early as 1948, the time has come a robust and sustainable surgical workforce.39 broader global to extend that relationship to the global sphere.36 Leveraging the critical importance of nonphysi- child health In short, promoting good global child health cian clinicians is essential in achieving this “all agenda.

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hands-on deck” approach.40 Although large varia- 19 years.50,51 There is an inverse association be- tions exist between countries, the volume of sur- tween prevalence of cesarean deliveries and gery performed by nonphysician providers can be maternal and neonatal mortality for cesarean de- significant: nearly 90% of obstetric surgeries and livery rates up to 19%.52,53 The Disease Control 39% of general surgery procedures—including Priorities Network noted that, as late as 2010, of 43% of nonobstetric laparotomies.39,41 Recent the worldwide 16 million DALYs lost due to studies seek to assess the safety and efficacy of maternal disorders, 6.4 million DALYs were attrib- these surgeries.42–44 Future work must continue utable to surgically preventable obstetric compli- to focus on evaluating the outcomes of task cations, including unsafe abortion.54,55 sharing, as well as articulating best practices for Children’s health care providers and surgery supporting trained nonspecialty providers. Addi- providers, alike, must work with obstetric providers tionally, attention to retention of workforce is crit- to improve access to obstetric care and coordinate ical. Previous studies have suggested that surgical the appropriate referrals to optimize maternal and By focusing on graduates in LMICs primarily migrate for “profes- neonatal care. Through a focus on these cost- 45 “best buy” sional reasons.” Attempts through National effective, “best buy” surgeries, the integration of surgeries, the Surgical Obstetric and Anesthesia Plans (NSOAPs, surgical care can be sustainable, allowing for mean- integration of discussed later) to improve training alongside in- ingful and lasting progress toward achieving the surgical care can frastructure may mitigate this problem. SDGs. be sustainable Although secondary benefits of integrating ’ and allow for efforts to increase a system s surgical capacity for Integrate Children’s Surgery Into NSOAPs meaningful children exist to strengthen the health system as In 2015, the Lancet Commission on Global progress toward a whole, this approach requires sustained invest- Surgery proposed a framework for the creation of ment over time. In the more immediate term, achieving the NSOAPs, providing an opportunity for govern- there may be an ongoing role for selective, vertical ’ SDGs. ments to strengthen surgical care. Children s sur- programs to avert DALYs today, while broader gery fits into this framework, and health officials health systems strengthening and capacity build- should be encouraged to integrate children’s sur- 46 ing are ongoing. In addition to the clinical gical care into both NSOAPs and national child impact of these surgical “camps,” potentials to en- health strategies. Nigeria has successfully included gage with local infrastructure and workforce ex- children’s surgery and nursing as a key compo- 47 ist. Each country must decide whether to use nent of their NSOAP.56 Additionally, children’s this intervention, and every effort must be taken health care providers and children’s surgeons that these interventions are well regulated and do must collaborate to ensure that academic, govern- not detract from the longer-term goal of an in- mental, and nongovernmental organizations work- crease in children’s surgical providers. ing on various child health priorities communicate and collaborate, not only with one another, but Focus on “Best Buy” Surgeries also with ministries of health. Moreover, enabling Children’s surgical care is cost-effective. In partic- the environment for children’s surgery requires at- ular, inguinal hernia repair, trichiasis surgery, tention to diverse domains, including infrastructure, cleft lip and palate repair, male circumcision, con- blood supply, infection control, and quality im- genital heart surgery, and orthopedic procedures provement. The NSOAP provides a mechanism for 57 are considered the 6 essential children’s surgical achieving this whole-of-systems approach. Using ’ procedures because of the economic value for the Lancet Commission s framework, all pediatric- the health burdens they avert.48 These proce- focused groups must advocate for the inclusion of dures, with the exception of congenital heart pediatric-specific interventions at the government surgery, align with the 44 procedures deemed “es- level into national and regional health planning us- 32 sential” by the Disease Control Priorities Network, ing the GICS Optimal Resources guide. a joint enterprise devoted to determine disease control priorities around the world, particularly Standardize Data Collection and Research in LMICs.49 Planning and effectively incorporating children’s Although not traditionally considered as “chil- surgery into national health systems is not possi- dren’s surgery,” reemphasizing the importance of ble without adequate and reliable information. cesarean deliveries must be included to address Recent strides have been made to improve data neonatal mortality and complications of pregnan- collection around children’s surgery,58–61 but cy, the leading cause of death for girls aged 15 to these efforts must be scaled, standardized, and

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aligned with existing surgical indicators as described in turn, arrives only with the support and collabo- by the Lancet Commission on Global Surgery (i.e., ration between children’s health care providers children’s surgical volume, access to care within and their colleagues. By aligning advocacy and 2 hours, workforce density, financial risk protection, fundraising efforts to include specific, cost- and perioperative mortality).62 Building off existing effective, and necessary surgeries, the global child initiatives such as the Quality of Care Network to en- health care and surgery communities can more ef- compass more children’s health areas is a potential fectively partner with countries to achieve this goal waytoscaleandstandardizetheseefforts.63 Addi- and offer comprehensive children’s health care to tionally, baseline assessments of the surgical services those who need it most. available at hospitals, such as through the District Health Information Software or Service Provision/ Conflicting interests: None declared. Service Availability and Readiness Assessments,64,65 need to be updated and emphasized to specifically REFERENCES 66 include children’ssurgery. Acombinedeffort 1. United Nations. 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Lancet Glob Heal. Pediatr. 2018;6:155. CrossRef. Medline 2017;5(10):e965–e966. CrossRef. Medline 21. World Health Organization. Congenital anomalies. Published 38. Toobaie A, Emil S, Ozgediz D, Krishnaswami S, Poenaru D. September 7, 2016. Accessed May 29, 2020. https://www.who. Pediatric surgical capacity in Africa: current status and future needs. int/news-room/fact-sheets/detail/congenital-anomalies J Pediatr Surg. 2017;52(5):843–848. CrossRef. Medline 22. Yousef Y, Lee A, Ayele F, Poenaru D. Delayed access to care and 39. Hoyler M, Hagander L, Gillies R, et al. Surgical care by non-surgeons unmet burden of pediatric surgical disease in resource-constrained in low-income and middle-income countries: a systematic review. – African countries. J Pediatr Surg. 2019;54(4):845 853. CrossRef. Lancet. 2015;385 Suppl 2:S42. CrossRef. Medline Medline 40. Federspiel F, Mukhopadhyay S, Milsom PJ, Scott JW, Riesel JN, 23. Poenaru D, Pemberton J, Cameron BH. The burden of waiting: DALYs Meara JG. Global surgical, obstetric, and anesthetic task shifting: a accrued from delayed access to pediatric surgery in Kenya and systematic literature review. Surgery. 2018;164(3):553–558. – Canada. J Pediatr Surg. 2015;50(5):765 770. CrossRef. Medline CrossRef. Medline 24. Poenaru D, Pemberton J, Frankfurter C, Cameron BH. Quantifying 41. Wren SM, Kushner AL. Task shifting in surgery-what US health care the disability from congenital anomalies averted through pediatric can learn from Ghana. JAMA Surg. 2019;154(9):860. CrossRef. surgery: a cross-sectional comparison of a pediatric surgical unit in Medline Kenya and Canada. World J Surg. 2015;39(9):2198–2206. CrossRef. Medline 42. Wilhelm TJ, Thawe IK, Mwatibu B, Mothes H, Post S. Efficacy of ma- jor general surgery performed by non-physician clinicians at a cen- 25. Poenaru D, Pemberton J, Frankfurter C, Cameron BH, Stolk E. tral hospital in Malawi. Trop Doct. 2011;41(2):71–75. CrossRef. Establishing disability weights for congenital pediatric surgical con- Medline ditions: a multi-modal approach. Popul Health Metr. 2017;15(1):8. CrossRef. Medline 43. Tariku Y, Gerum T, Mekonen M, Takele H. Surgical task shifting helps reduce neonatal mortality in Ethiopia: a retrospective cohort study. 26. Mock CN, Donkor P, Gawande A, Jamison DT, Kruk ME, Debas HT. Surg Res Pract. 2019;2019:5367068. CrossRef. Medline Essential surgery: key messages of this volume. In: In: Debas HT, Donkor P, Gawande A, et al., eds. Essential Surgery Disease Control 44. Beard JH, Ohene-Yeboah M, Tabiri S, et al. Outcomes after inguinal Priorities. 3rd ed. The International Bank for Reconstruction and hernia repair with mesh performed by medical doctors and surgeons Development, The World Bank; 2015. Accessed May 29, 2020. in Ghana. JAMA Surg. 2019;154(9):853–859. CrossRef. Medline https://www.ncbi.nlm.nih.gov/books/NBK333511/ 45. Hagander LE, Hughes CD, Nash K, et al. Surgeon migration between 27. Krishnaswami S, Nwomeh BC, Ameh EA. The pediatric surgery developing countries and the United States: train, retain, and gain workforce in low- and middle-income countries: problems and pri- from brain drain. World J Surg. 2013;37:14–23. CrossRef. Medline – orities. Semin Pediatr Surg. 2016;25(1):32 42. CrossRef. Medline 46. Moon W, Perry H, Baek RM. Is international volunteer surgery for 28. Chirdan LB, Ameh EA, Abantanga FA, Sidler D, Elhalaby EA. cleft lip and cleft palate a cost-effective and justifiable intervention? a Challenges of training and delivery of pediatric surgical services in case study from East Asia. World J Surg. 2012;36(12):2819–2830. Africa. J Pediatr Surg. 2010;45(3):610–618. CrossRef. Medline CrossRef. Medline 29. Dubowitz G, Detlefs S, McQueen KAK. Global anesthesia workforce 47. Blair GK, Duffy D, Birabwa-Male D, et al. 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49. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN. 59. Elhalaby EA, Millar AJW. Challenges of pediatric surgical practice in Essential Surgery. The International Bank for Reconstruction and Africa. Preface. Semin Pediatr Surg. 2012;21(2):101–102. Development, The World Bank; 2015. CrossRef. Medline 50. Alkema L, Chou D, Hogan D, et al. Global, regional, and national 60. Greenberg SLM, Ng-Kamstra JS, Ameh EA, Ozgediz DE, Poenaru levels and trends in maternal mortality between 1990 and 2015, D. An investment in knowledge: research in global pediatric surgery with scenario-based projections to 2030: a systematic analysis by the for the 21st century. Semin Pediatr Surg. 2016;25(1):51–60. UN Maternal Mortality Estimation Inter-Agency Group. 2016;387 CrossRef. Medline (10017):462–474. CrossRef. Medline 61. Hamad D, Yousef Y, Caminsky NG, et al. Defining the critical pedi- 51. Filippi V, Chou D, Ronsmans C, Graham W, Say L. Levels and causes atric surgical workforce density for improving surgical outcomes: a of maternal mortality and morbidity. In: Black RE, Laxminarayan R, global study. J Pediatr Surg. 2020;55(3):493–512. CrossRef. Temmerman M, et al., eds. Reproductive, Maternal, Newborn, and Medline Child Health: Disease Control Priorities. 3rd ed. The International Bank for Reconstruction and Development/The World Bank; 2016. 62. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic 52. Maswime S. Improving access to caesarean sections and periopera- development. Int J Obstet Anesth. 2016;25:75–78. CrossRef. – tive care in LMICs. Lancet. 2019;393(10184):1919 1920. Medline CrossRef. Medline 63. About Us. Network for Improving Quality of Care for Maternal, 53. Molina G, Weiser TG, Lipsitz SR, et al. Relationship between cesare- Newborn and Child Health website. Accessed April 6, 2020. http:// an delivery rate and maternal and neonatal mortality. JAMA. qualityofcarenetwork.org/about 2015;314(21):2263–2270. CrossRef. Medline 64. DHIS2 home page. DHIS2 website. Accessed May 29, 2020. 54. Johnson CT, Johnson TRB, Adanu RMK. Global burden of surgically https://www.dhis2.org/ treatable obstetric conditions. In: Debas HT, Donkor, P, Gawande A, et al., eds. Essential Surgery: Disease Control Priorities. 3rd ed. The 65. Sheffel A, Karp C, Creanga AA. Use of Service Provision International Bank for Reconstruction and Development/The World Assessments and Service Availability and Readiness Assessments for Bank; 2015. monitoring quality of maternal and newborn health services in low- 55. Higashi H, Barendregt JJ, Kassebaum NJ, Weiser TG, Bickler SW, income and middle-income countries. BMJ Glob Heal. 2018;3(6): Vos T. Surgically avertable burden of obstetric conditions in low- and e001011. CrossRef. Medline middle-income regions: A modelled analysis. BJOG. 2015;122 66. Lancet Commission on Global Surgery, World Health Organization (2):228–236. CrossRef. Medline (WHO), Program in Global Surgery and Social Change (PGSSC), 56. Peters AW, Roa L, Rwamasirabo E, et al. National Surgical, Harvard Medical School. WHO-PGSSC Surgical Assessment Tool Obstetric, and Anesthesia Plans Supporting the Vision of Universal (SAT) Hospital Walkthrough. Accessed July 30, 2018. https:// Health Coverage. Glob Heal Sci Pract. 2020;8(1):1–9. CrossRef. b6cf2cfd-eb09-4859-92a9-a8f002c3bcef.filesusr.com/ugd/ Medline 346076_b9d8e8796eb945fe9bac7e7e35c512b1.pdf 57. deVries CR, Rosenberg JS. Global Surgical Ecosystems: A Need for 67. Poenaru D, Seyi-Olajide JO. Developing metrics to define progress Systems Strengthening. Ann Glob Heal. 2016;82(4):605–613. in children’s surgery. World J Surg. 2019;43(6):1456–1465. CrossRef. Medline CrossRef. Medline 58. Butler MW, Ozgediz D, Poenaru D, et al. The Global Paediatric 68. Peters AW, Pyda J, Menon G, Suzuki E, Meara JG. The World Surgery Network: a model of subspecialty collaboration within Bank Group: innovative financing for health and opportunities global surgery. World J Surg. 2015;39(2):335–342. CrossRef. for global surgery. Surgery. 2019;165(2):263–272. CrossRef. Medline Medline

Peer Reviewed

Received: December 19, 2019; Accepted: May 19, 2020

Cite this article as: Wasserman I, Peters AW, Roa L, Amanullah F, Samad L. Breaking silos: improving global child health through essential surgical care. Glob Health Sci Pract. 2020;8(2):183-189. https://doi.org/10.9745/GHSP-D-20-00009

© Wasserman et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-20-00009

Global Health: Science and Practice 2020 | Volume 8 | Number 2 189 ORIGINAL ARTICLE

District Health Teams’ Readiness to Institutionalize Integrated Community Case Management in the Uganda Local Health Systems: A Repeated Qualitative Study Agnes Nanyonjo,a Edmound Kertho,a James Tibenderana,b Karin Källanderc

Key Findings ABSTRACT Introduction: Several countries have adopted integrated commu- n Despite district health teams reporting readiness and nity case management (iCCM) as a strategy for improved health preparation to incorporate integrated community case service delivery in areas with poor health facility coverage. Early management (iCCM) into their district health systems, implementation of iCCM is often run by nongovernmental organi- they were unable to institutionalize most components zations financed by donors through projects. Such projects risk into district-specific work plans. failure to transition into programs run by the local health system upon project closure. Engagement of subnational health authori- n Barriers to institutionalization included the lack of ties such as district health teams (DHTs) is essential for a smooth stewardship from both Ministry of Health and transition. implementing partners on how to transition from a Methods: We used a repeated qualitative study design to assess partner-supported to a locally-run program, lack of the readiness of and progress made by DHTs in institutionalizing agreement of national guidelines on community-level iCCM into the functions of locally decentralized health systems in drug distribution, lack of integration of some iCCM 9 western Uganda districts. Readiness data were derived from indicators in the national health management structured group interviews with DHTs before iCCM policy adop- information system, and limited central government tion in 2010 and again in 2015. Progressive institutionalization funding. achievements were assessed through key informant interviews with targeted DHT members and local government district plan- Key Implications ners in the same areas. Findings: In the readiness study, DHTs expressed commitment to institutionalize iCCM into the local health system through the de- n District health teams and other local government velopment of district-specific iCCM activity work plans and bud- administrative structures should work together to gets. The DHTs further suggested that they would implement increase community acceptance, engagement, and district-led training, motivation, and supervision of community ownership of interventions. health workers; procurement of iCCM medicines and supplies; n National and local health systems and implementing and advocacy activities for inclusion of iCCM indicators into the partners should collaborate to complement national health information systems. After iCCM policy adoption, community engagement and encourage local follow-up study data findings showed that iCCM was largely not in- ownership and effective institutionalization. stitutionalized into the local district health system functions. The poor institutionalization was attributed to lack of stewardship on how to n Central government authorities should increase transition from externally supported implementation to district-led capacity building of district health teams by providing programming, conflicting guidelines on community distribution of training, delegating power, and providing tools and medicines, poor community-level accountability systems, and limited technologies for implementing iCCM. decision-making autonomy at the district level. n Implementing partners should collaborate with the Conclusion: Successful institutionalization of iCCM requires local Ministry of Health and other relevant policy makers ownership with increased coordination and cooperation among to put into place an effective phaseout and eventual governmental and nongovernmental actors at both the national exit plan that will ensure program sustainability. and district levels.

a Malaria Consortium Uganda, Kampala, Uganda. INTRODUCTION b Malaria Consortium, London, UK. c Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. Compared to the rest of the world, sub-Saharan Africa Correspondence to: Agnes Nanyonjo ([email protected]). still suffers from significant under-5 mortality

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despite making remarkable improvements.1,2 decentralization reforms based on the local gov- Disparities in under-5 mortality persist among ernment system experienced since 1986. sub-Saharan countries and between the richest Decentralization has been defined as the transfer and the poorest households.3 Infectious diseases of some degree of political, administrative, and fi- continue to account for a sizable proportion of nancial authority from the central government to the region’s under-5 mortality. Diarrhea, malaria, the local governments.14,15 The local government and pneumonia combined accounted for approxi- system consists of administratively nonsubordi- mately 40% of under-5 mortality between 1999 nated, comprehensive, and judicially accountable and 2013 compared to the 29% global estimate.4 local districts. Thus, the decentralized systems Between 2000 and 2015, pneumonia (16.6%) were expected to improve access to public services replaced malaria (16.4%) as the leading cause of based on community needs, develop local capaci- mortality among children aged 1–59 months in sub- ty, and enhance transparency and accountability Saharan Africa.5 through community participation. In the last 2 The United Nations Children’s Fund and the decades, districts in Uganda have gradually gained World Health Organization (WHO) recommend some degree of financial decentralization. To be integrated community case management (iCCM) sure, most local governments are still financed by of childhood illnesses as a strategy for equitable ac- funds allocated from the central government, al- cess to treatment in areas with formal health facil- though each district has the power to supplement ity deficiency.6 iCCM relies on community health centrally funded budgets with locally generated workers (CHWs) using simple algorithms to offer revenue and approved budgets.16 health promotion, disease prevention, and cura- In the health systems context, the decentrali- tive services for uncomplicated diarrhea, malaria, zation reforms in Uganda meant that the principal and pneumonia.6 In 2002, Uganda adopted the roles of the central Ministry of Health (MOH) were Home-Based Management of Fever policy for redirected to policy formulation, capacity devel- management of malaria, and, in 2010, adopted opment, planning, inspection, mobilization of the iCCM policy that also introduced CHW train- resources (such as human resources, health infra- ing in integrated management of pneumonia and structure, medicines, and other health supplies, as diarrhea within the community.7 well as health data), and provision of nationally Appropriate implementation of integrated coordinated services including the management interventions like iCCM tends to be complex be- of national programs. The national programs run cause interrelated yet independent interventions by the MOH include but are not limited to epidem- are packaged and delivered together.8 The inte- ic control, emergency preparedness research, and grated interventions rely on local health system monitoring and evaluation of health sector perfor- structures and resources for their implementation. mance. On behalf of the MOH, several national Thus, it is important to ensure that the various interventions are packaged in a manner that allow them to be absorbed by the local health system.9,10 Specifically, the interventions need to be institu- tionalized into the different but interconnected departments through which local health systems deliver health care.11,12 In theory, institutionaliza- tion of a health intervention into the health system is believed to occur when the intervention becomes a routinely practiced and integral part of the conventional health system. Thus, institution- alization of iCCM depends on the implementation of a strong iCCM program, which, in turn, requires appropriate CHW training, regular super- vision and monitoring, and continuous supply of drugs and commodities among other things.13 The local health system in Uganda is based A village health team member counts the respiratory rate of a child who on a decentralized system arising from political has a cough with fast breathing. Photo credit: © 2013 Edmound Kertho

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improvement, has been recognized as a key barri- er to health systems performance.23 In Uganda, iCCM was gradually introduced into a decentra- lized health system through the village health team (VHT) strategy that outlines the DHT’s re- sponsibility for overall planning, implementation, and monitoring of VHT activities, and that VHT ac- tivities shall be fully integrated into the district health development and operational plans.24 We conducted this study to assess the baseline readiness and progress made by DHTs in institu- tionalizing iCCM into the local health system 25,26 A supervisor shows village health team members how to fill in the iCCM functions. Community or organization readi- register during a quarterly review meeting. Photo credit: © 2013 ness studies are important in determining wheth- Edmound Kertho er a program can be effectively implemented and supported by a community. autonomous units, including the Uganda Blood Transfusion Service, national medical stores METHODS (NMS), various health professional councils, and the National Drug Authority, operate some of Study Design the clinical support and regulatory functions.17 We used a repeated qualitative assessment con- Consequently, because districts have the overall sisting of group and key informant interviews in responsibilities for health service delivery,18 to a 9 districts in western Uganda. The baseline readi- large extent, the district health team (DHT) oper- ness study was conducted just before the launch ates the local health system. The DHT consists of of the iCCM policy in 2010 and the follow-up technical health officials responsible for strategic study was conducted in 2015. health planning, management, budgeting, coordi- nation, resource mobilization, and monitoring of Study Setting overall district health performance. iCCM Implementation Context In the process of institutionalizing integrated Since the 2010 launch of the iCCM policy in health interventions into decentralized health sys- Uganda, subsequent implementation had been tems, both departments and individuals have of- mainly run by implementing partners in collabo- 27 ten encountered disruptions.19,20 For example, ration with local district health administrators. health facility workers with the double burden of The implementing partners largely consisted of lo- cal nongovernmental and international organiza- providing clinical and administrative services may tions. The national implementation of iCCM was also be required to take on additional iCCM super- undergoing expansion at the time of the study, visory roles. Such disruptions may lead to com- and it was estimated to have reached 78 of the promised quality of care and delays in achieving 112 districts in Uganda by the end of 2016. There equity as local health systems cope with both were also government-led efforts to integrate high disease burden and limited resources.14 iCCM into national plans and budgets.27 Previous research has shown that achievement and sustainability of meaningful benefits of iCCM Various Actors’ Roles in Implementing iCCM requires adequate health system and political sup- Malaria Consortium port. Such support is in the form of ongoing CHW Malaria Consortium, an international nongovern- training, supportive supervision, provision and mental organization, was the main iCCM imple- replenishment of effective job aids, consistent re- menting partner in the study area between plenishment of medicines and supplies, and effec- 2010 and 2015. It worked closely with the MOH tive approaches for retention and performance of to support and strengthen community-based case CHWs.21,22 Although the importance of DHT staff management programs for malaria, pneumonia, empowerment for effective management has been and diarrhea while emphasizing linkages to for- highlighted, the lack of capacity in exercising a de- mal health services. Malaria Consortium’s ap- cision space for critical health system functions, proach to the implementation of iCCM followed a such as human resource management and quality health systems strengthening (HSS) approach.28

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We actively participated in technical working health facility staff and other supervisors from the groups and proactively provided progress updates local government. DHTs collaborated with the to harmonize the program with national policies Malaria Consortium in digitizing the quarterly without compromising those elements that we be- reporting of iCCM data into a system known as lieved were essential to achieving a high-quality the District Health Information System II. During health care program. These components included the study period, DHTs ensured regular supply of supportive supervision, effective referral systems, medicines for iCCM through adequate forecasting, supply management of medicines and other quantification, and distribution of medicines. A commodities to minimize stock-outs, as well as detailed description of the responsibilities of the strong monitoring and evaluation of the program health facility workers and CHWs trained follows. through routine data collection from VHTs. Thus, we covered several iCCM costs through provision District, Local Government, and Health Systems of free diagnostics and medicines, VHT training on Context iCCM alongside DHT members, job aids, data col- ’ lection registers, supervision, and behavioral Uganda s districts are divided into counties, sub- change communication for caretakers and health counties, parishes, and villages. The village is gov- staff. To support the institutionalization of iCCM, erned by the local council, which is headed by a we supported the quantification of iCCM supplies chairman. Within the formal health sector struc- stock at the central level. At the district level, we ture, a hospital serves a district, a health center facilitated learning visits, supported budgeting level IV serves a county (also known as a health and forecasting exercises, and supported local subdistrict), a health center level III serves a sub- supervision of VHTs and data collection through county, and a health center level II serves a parish. parish coordinators. We undertook all the afore- A VHT member, also known as a CHW, work- mentioned activities under the stewardship of the ing from home is considered the health center Maternal and Child Health Division of the MOH level I at the village level overseeing between and other related divisions. All our activities were 20–30 households. A VHT comprises 5–6 CHWs geared toward supporting DHTs and the MOH to who received 5 days of training on disease preven- take local ownership of iCCM and include its costs tion and health promotion. The community and activities into their work plans. selects 2 VHT members to participate in an addi- tional 6-day iCCM training that is supervised by a MOH health facility worker.24,26 The training prepares The MOH worked closely with key iCCM imple- the VHT members to classify and treat uncompli- menting partners to develop and translate the na- cated malaria, pneumonia, and diarrhea using tional iCCM policy and guidelines into practice at simple algorithms, simple diagnostic tests, and the community level. This work was done primar- standard treatment regimens that are color coded. ily by developing tools for implementation of It also prepares them to refer sick newborns and different aspects of the policy, such as training children with malnutrition and symptoms of se- materials and curriculum; support supervision vere illness to higher-level health facilities.26 forms; registers and data collection forms; and Typically, staff from the nearest health facility su- stock management forms. Staff from the MOH pervise and support the VHT members. acted as trainers and supervisors for iCCM pro- The DHTs forecast the quantities of medicines grams. The MOH adopted diagnostic tools and and supplies that health facilities will need, re- color-coded treatment regimens suitable for the quest the quantities from the NMS, and then dis- treatment of young children by CHWs in response tribute the commodities to the lower-level health to advocacy from the implementing partners. facilities based on perceived need as assessed by a higher-level facility. The health facility in-charge DHTs and the assistant health education officer at the After the DHT members received training from the health subdistrict are the custodians of supplies Malaria Consortium, DHT members served as and commodities that the VHTs use, whereas the iCCM trainers. Together with staff from the health facilities at all levels are responsible for Consortium, DHT members conducted training replenishment of commodities and health sup- for staff from all levels of health facilities and plies.24,26 Figure 1 illustrates the hierarchy of CHWs. DHT members also acted as supervisors of both health and administrative systems in iCCM to manage the supervision of CHWs by Uganda.

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FIGURE 1. Uganda’s Health and Administrative System Structure

Study Sites (Table 1). In addition, we conducted key infor- Our study drew on data collected from 9 districts mant interviews with selected DHT members in midwestern and central Uganda (Table 1) who oversaw the implementation of community- where the Malaria Consortium (one of the largest based interventions (including iCCM) and the dis- implementing partners) had been implementing trict planners who managed the district budget. iCCM since 2009. The districts had an estimated The structured interview guides used for both the total population of 2.2 million, of which 20% were group and key informant interviews were framed under-5-year-old children. The districts were served within the WHO health system building blocks. by a total of 276 health facilities, 70% of which were The group interview facilitators asked targeted government health facilities, 18% were private questions about planned strategies to institution- not-for-profit, and 12% were private for-profit. The alize iCCM into local health system functions. health-seeking behavior of thepeopleinthestudyis Table 2 gives an overview of the health system known to vary from treatments at home to both functions that were explored. formal and informal health providers outside the In 2015, the progress made in institutionaliz- home.29 ing iCCM into the functions of the local health system was explored by conducting an identical semistructured interview of DHT members and Study Participants and Data Collection district planners from the same districts. The inter- In 2010, we collected data on readiness of DHTs to viewer asked questions on progress made and institutionalize iCCM into local health systems’ the most significant changes observed in imple- functions during the period that preceded the menting various iCCM components into the func- adoption of the national iCCM policy. Data were tions of the local health system. collected through structured group interviews All group interviews and key informant inter- held with DHT members in each of the 9 districts views were conducted in English, audiotaped, and

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TABLE 1. Profile of District Health Team and Local Government Members Interviewed on Institutionalizing Integrated Community Case Management, 9 Districts in Uganda

Readiness Study Group Interview Participants Buliisa Kibaale Kiboga Kyankwanzi Kyenjojo Kyegegwa Kiryandongo Masindi Hoima

District health officer X X X X X X X X X District drug inspector X X X X X X District health inspector X X X X X X X District health educator X X X X X X X X X District surveillance focal person X X X Health facility in-charge X X X X X X X X X Health management information focal person X X X Malaria focal person X X X X X X X Medical superintendent X X District biostatistician X X X X Key informant follow-up studya,b District health officer N Y N Y Y Y Y Y Y Malaria focal person Y Y N Y Y Y Y Y Y District biostatistician/HMIS focal person Y Y Y Y Y Y Y Y Y District planner N/A N/A N/A N/A N/A N/A N/A N/A N/A

Abbreviation: HMIS, health management information system. a Y means a person was district health team member in 2010 and 2015 and participated in the study. b N means person was not a district health team member in 2010. were available as verbatim transcripts. Permission categories relating to the health system compo- was obtained by a notetaker to both audiotape and nents and functions, including financing, service write out the discussion that ensued. Permission delivery, health workforce, governance, medical for the audio recording was also explicitly sought products and technologies, and information in the consent form that all study participants (Table 2).30 The analysis aimed to explore the ex- were required to complete. tent to which iCCM had been institutionalized In situations when a particular DHT member into the health system building blocks and func- was not available, the acting or designated person tions at the district level as proposed by the DHT with those responsibilities was interviewed in- before the iCCM policy adoption period. The anal- stead. The individuals interviewed in the baseline ysis was done using OpenCode 4.0 (University of readiness and follow-up studies were often the Umeå, Sweden). same, except for DHT members who had left, been promoted or transferred, or had died. The individuals were purposively sampled based on Ethical Considerations Ethical approval for the study was obtained as part their roles and the fact that they were believed to of the inSCALE study from both the Institutional have rich information on strategic health planning Review Board of Makerere University School of for the district. Public Health (IRB00011353 protocol [100]) and the Uganda National Council of Science and Data Analysis Technology (HS 958). Informed consent was Using deductive content analysis, data were ex- obtained from the study participants. plored for patterns related to the different health system functions by the first author (AN). Meaning units were identified directly from what RESULTS respondents said. These were condensed into de- In the pre-iCCM policy adoption readiness study, scriptive codes that were fitted into the predefined we found that the DHT reported being ready to

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TABLE 2. World Health Organization Health System Building Blocks (Functions) Explored in 9 Districts in Uganda

Attributes Probed for in the Interview Guide

Health financing  Sources of funding for health care in general and specifically for iCCM  Percentage of the district budget allocated to iCCM  Type of providers of child health care services  Range of health services provided by both public and private providers and coverage of the health costs at the point of use  Most significant change in health financing for children

Service delivery  Scope of child services offered within the district-by whom and when and presence of any performance linked payments  The most significant change in health service delivery

Health workforce  Scope of health staffing levels and turnover in the district  Scope of VHT coverage and turning over  Scope of training, implementation partners, remuneration, motivation. and supervision for CHWs  Presence and awareness of iCCM guidelines  Most significant in the health workforce

Governance  Extent to which health decisions are made by the DHTs  Budget priority setting exercises  Health worker and health technology regulation  Community participation in health decision making  Most significant changes in health governance

Medical products and  Available medicines and supplies for treatment of common childhood illnesses technologies  Distribution of the medicines and supplies specifically iCCM medicines  Most significant change in distribution of medicines

Information  Management of health data at the local and district level  Availability of standardized registers for collecting and submitting community level data  Available data submission platforms  Community-level indicators fitted into the national HMIS  Use of data for decision making at local and district level  Key challenges in reporting data at the local and district level  Most significant change in the HMIS

Abbreviations: CHW, community health worker; DHT, district health team; HMIS, health management information system, iCCM, integrated community case management; VHT, village health team.

Although DHT institutionalize iCCM into their district health sys- iCCM components into the health systems functions reported being tems. They affirmed their readiness by mentioning ranged from poor to none at all. ready to institu- plans to develop district-specific iCCM activity tionalize iCCM, work plans and budgets; district-led training, moti- follow-up study vation and supervision of CHWs; district-led distri- Lack of Financing of iCCM findings showed bution of iCCM drugs and supplies; and advocacy In the readiness study, DHTs suggested that they the level of institu- activities for including iCCM indicators into the na- would ensure sustainable funding for iCCM. They tionalization tional health management information system planned to realistically achieve this by avoiding ranged from poor (HMIS). In contrast, in the follow-up study, we excessive dependency on donor funds. The DHTs to none at all. found that the level of institutionalization of most often mentioned their plans to advocate for the

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inclusion of an iCCM budget in district work plans interviewed in the postadoption period conceded and only mobilize donor funds as supplementary that a well-running iCCM program was beneficial budgets from their district implementing partners. and could lead to decongestion of health facilities Such supplementary funds would include start-up and improved health-seeking behavior in the costs linked to the VHT training among other communities. things. Generally, [iCCM] improved service delivery and queues We intend to partner with the different nongovernmen- shortened at the health facilities. The few health work- tal organizations working in different localities in ers were not burdened by the workload anymore at our area to train VHTs. —DHT member, group health facilities ...and the blood test [malaria rap- interview, 2010 id diagnostic test] is now more available and demanded for ... so I think those are some of the The follow-up interviews revealed that financ- changes. —District health officer, interview, 2015 ing for iCCM to procure medicines and supplies, train CHWs, and facilitate quarterly supervision meetings remained largely donor dependent. DHTs had difficulties including an iCCM budget Lack of Institutionalization of iCCM Medicines in the district work plan and struggled to deter- Overall, the post-iCCM policy adoption findings mine what budgetary lines could be used to cover were not in line with procurement and supply iCCM-related costs. Most of the district health management system plans indicated by the DHTs budget was provided by central government funds in the readiness study. DHTs had previously pro- to the districts in a lump sum. These funds needed posed advocating for the supply of iCCM drugs to be distributed among many competing health and supplies through the NMS with a push system priorities based on budgetary ceilings. DHTs from for medicines in hard-to-reach areas. The DHTs across all study districts reported the largest per- reported that their plans for procurement were centage of the central government funds allocated based on some of the lessons that they had learned to health were apportioned to health facility run- during the implementation of the preceding ning costs. This left meager funds for other activi- Home-Based Management of Fever national pro- ties including community health. The health gram. DHTs recognized that the availability of budget from the central government was supple- medicines and supplies acted as a motivating fac- – mented by 13% 16% of locally generated reve- tor for VHTs, but drug stocks-outs did the opposite. nue; an insufficient amount to cover the activities They often mentioned that demotivation among in the iCCM district plan. The shortage in locally VHTs due to drug stock-outs often manifested as generated revenue is due to the fact that tax col- concurrent neglect of the regular health promo- lection in rural areas is often limited and varies ev- tion and education activities among some VHTs. ery year depending on how much property tax, local service tax service, parking fees, and district ...with regard to motivation, when Coartem is present, rental fees are collected. the VHTs are very active. We shall do whatever is within our power to ensure full-time stocking of drugs and sup- For example [during the budgeting exercise], the health plies, but then again, this factor [availability of drugs] is facilities receive the PHC funds [primary health care greatly dependent on dynamics within the NMS [in ref- funds] directly from the central government into their erence to inefficiencies in the wider procurement and accounts. It is the in-charge of that facility who is the ac- supply cycle]. —DHT member, group interview, counting officer together with the subcounty chief. So, 2010 they do their work plan and budget. We only do the su- pervision to see whether they comply with what is in Despite this assertion, half a decade post-iCCM their work plan. Health facilities also have health man- policy adoption, the delivery of medicines and agement committees. They [health facility leadership] commodities to the community level came to a look at previous budget performance as they bring the complete halt in 8 of the 9 districts after departure management committee on board, and we are encourag- of the implementing partners. ing them to bring VHTs on board too. From there, the We do not have a budget line for [iCCM] as a district. It is budgets go to the health subdistrict from where they are also quite complex to requisition for drugs. NMS has a approved. —District health inspector, interview, policy not to distribute medicines to the community, 2015 and the VHTs are considered not professionally trained Although no concrete iCCM financing plans to handle medicine. NMS considers only health center II existed in most of the districts, DHT members and health center III. There are also no clear guidelines

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on how to requisition VHT commodities from community and had managed to avert interrup- NMS. —Malaria focal person, interview, 2015 tions in program implementation by the time of the study. DHTs felt they Overall, the DHTs felt that they lacked stew- lacked ardship, clear instructions, and direction from Actually, NMS has not supplied [iCCM drugs and sup- stewardship and both the implementing partners and the MOH plies]. They promised, but they have not started. [NMS] clear instructions on how best to transition from externally sup- were saying that they have not quantified what is need- on medicine ported implementation to district-led program- ed and are still sorting out some policy issues ...but ini- distribution. ming. More elaborately, the DHTs had no clear tially, with our partners’ support, the VHTs used to get guidelines or directives from the MOH on how to the drugs during quarterly meetings or at times the transition to a district-led community medicine health workers would take the drugs to them. Now, in distribution policy. There were also conflicting case of a drug shortage, there is a form VHTs fill out community medicine distribution policies that and write a requisition form for drugs in the presence were prone to different interpretations by the var- of the chairman local council level I who also signs the ious DHTs. These included the iCCM guidelines, form that is taken to the health facility in order to receive which allowed for the prescription of amoxicillin drugs. It is a local arrangement that we are trying at the community level, and the National Drug out. —Malaria focal person, interview, 2015 Redistribution Policy, which allowed for the redis- One more district mentioned its intent to pilot tribution of medicines and commodities between district-led iCCM service delivery in 1 subcounty different levels of health facilities in cases of in the near future. shortages but not the prescription of antibiotics at the community level. Due to these conflicting We want to interest our implementing partners to come guidelines, and the complete absence of standard back because we have gaps. Presently, there are no drugs accountability tools at the community level, the in the communities [for the VHTs] because the govern- integration of iCCM medicines and commodities ment has not incorporated iCCM into its policies. We in- into district procurement chains was not per- formed the MOH during workshops or whenever ceived as a viable option for most DHTs. there was a chance. The MOH okays us to go ahead and implement iCCM, but they do it verbally, so we Successful Institutionalization of iCCM fear to implement it unless it is put in writing. Medicine Procurement However, there are some health centers where we are pilot- ’ Despite the conflicting community medicine dis- ing [commodity distribution from the health facilities — tribution guidelines, the follow-up study showed stocks]. District health educator, interview, 2015 that 1 district used the National Drug Redistribu- tion Policy to provide iCCM services in at least Increased Availability and Strengthened 2 of its 4 subcounties for the start with intent to Percentage of Human Resources for iCCM expand to all its subcounties. The 2 subcounty im- VHTs trained on DHTs reported that the percentage of VHTs trained plementation phase was a DHT-led demonstration basic package on the basic package per subcounty compared to project (pilot) undertaken to understand the best increased to more that required by the national VHT strategy in- approaches for transitioning to an independent than 90% in all creased from a range of 0%–64% pre-iCCM to district-led iCCM program. However, the demon- study districts. more than 90% in all study districts in the follow- stration project also faced several challenges as the up study. This increase was attributed to the con- DHT had to develop a robust accountability system certed efforts of nongovernmental district imple- for distributing community-level medicines and mentation partners. In the readiness study, DHTs commodities on its own. The system consisted of suggested that they would include VHT training collaborative efforts between the head of the polit- budgets in their work plans, orient health facility staff ical domain at the village (local council chairman) on iCCM, and develop concrete supervision and mo- and VHTs. Through this system, VHTs were able to tivation plans in accordance with MOH protocols, as requisition for and receive drugs from the health some of the key strategies for retaining VHTs. They facility under the witness of the local council level believed that the training led by nongovernmental I chairman who was required to append a signa- organizations was more aligned to individual nongo- ture on both the requisition and delivery (receipt) vernmental organization goals than district interests forms. Thus, medicines and commodities redis- and should thus gradually be weaned off. tributed to the community levels were accounted for as stock used by the outpatient department. We have different VHTs with different motivating fac- The arrangement was well received by the tors and different training. For example, X [name of

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organization withheld] trains VHTs on HIV, and XX ... they [VHTs] received training in theory and were [name of organization withheld] trains them on oncho- provided with the registers later on. They did not know cerciasis ... VHTs trained by XXX are motivated be- how to fill the registers properly, and this frustrated not cause they receive motivators like umbrellas and only them but also the records staff. —DHT member, gumboots; partners need to cooperate to harmonize group interview, 2010 VHT activities and remuneration as people working to- However, in the follow-up study, community- ward a common goal which is improving community level data reporting did not align with the health in line with MOH guidelines. —DHT member, improvements that had initially been suggested group interview, 2010 by the DHTs in the readiness study. Community- Contrary to the readiness study, the follow-up level data were submitted from health facilities to study showed that there were no clearly defined the district level every quarter because monthly district-led training, motivation, and supervision submissions were considered cumbersome and plans for the VHTs. DHTs were not yet prepared unpractical. The quarterly report submitted cap- to transition from partner-led to district-led activ- tured absolute numbers of children treated for ities. The motivation and supervision of VHTs was specific diseases but not the medicines dispensed happening on an ad hoc basis as it had initially to the children. According to some, this was a con- depended on implementing partners for financial sequence of some implementing partners provid- and technical support. The DHTs reported that ing VHT registers and reporting forms that did not once the implementation partners left, the su- match the indicators captured by the HMIS. pervision became increasingly irregular and in- At first, the data were managed by the donor, but later it frequent. Remarkably, in the majority of the was entered in HMIS after we got pressure from the gov- study districts, supervisors encouraged VHTs to ernment. We have just completed entering the iCCM form self-help groups and engage in income- data from 2009 up to last year. The donor’s tool was generating activities such as savings and credit not matching with the HMIS data base. Now, the cooperative organizations that could improve HMIS 097 is the quarterly reporting form for motivation without necessarily depending on iCCM. —District biostatistician, interview, 2015 district resources. It [district-led motivation of VHTs] has been somehow minimal. Of course, our VHTs have been having Lack of Coordination and Governance of a high interest to perform but have been experiencing iCCM demotivating factors like stock-out of drugs. However, Although nearly half a decade had elapsed after the district receives drugs from NMS. So as a district, I the national adoption of the iCCM policy, the cannot say we have a plan to retain these VHTs; it also DHTs did not clearly mention any effective strate- depends on their functionality. Actually, what we are gies had been used for policy implementation on doing is that we integrate them in our health system, the ground. iCCM had not been comprehensively for example, by asking them to do services like mass institutionalized into district-specific work plans mobilization. —Malaria focal person, interview, with several requirements that would have other- 2015 wise led to its effective implementation reported to be lacking. The existing national policies did not offer guidance on how to transition from Lack of Institutionalization of Community partner-led programs to district-led ones, and the Data into the HMIS guidelines that existed did not allow DHTs enough In the readiness study, DHTs often acknowledged formal decision-making autonomy regarding bud- a need for improved reporting and use of geting and implementation. This was manifested community-level data for district planning on a at several functional levels of the health system: routine basis. The DHTs proposed advocating for (1) finance and expenditure allocations were harmonization of community-level data collec- based on government-set ceilings that limited the tion tools with the HMIS (since some community- allocation of funding to iCCM activities, (2) DHTs level indicators were not being captured by the were uncomfortable to make decisions concerning existing HMIS forms) and emphasized the impor- the drug supply for community medicines that tance of VHT training on registers, timely provi- resulted in drug stock-outs, and (3) DHTs were sion of registers, and coordination and facilitation not able to make decisions about health informa- of data submission as some of the strategies for im- tion system reporting to the central level. proved community-level data submission. Nonetheless, there was a high level of awareness

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of iCCM in the districts, and there were plans to to act independently and make their own free include VHTs in the district budget priority- choices) among DHT members. setting exercises in some of the districts. The challenges experienced by the DHTs in These findings were not concordant with the Uganda resonate with those documented in level of commitment to develop comprehensive iCCM programs elsewhere in sub-Saharan – district-specific work plans for iCCM that was Africa.31 33 These findings underscore the missing expressed in the readiness study when DHTs had link between strengthening of a community proposed that comprehensive work plans would health systems in relation to the wider health sys- encompass consolidated community sensitization tem. Strengthening of the community-based sys- plans, VHT supervisions plans, and VHT motiva- tem in isolation from the higher levels of the tion plans to sustain implementation. health systems is prone to fragmentation and inef- ficiency. For example, it is more beneficial to We have no VHTs at the moment. We have a DHT. We strengthen the entire health system supply chain plan on recruiting enough staff at the health facility lev- than to focus on the community supply chain el. We have made iCCM known to the health subdis- alone. Similarly, the lack of harmonization be- tricts, and we shall make it known to the community. tween iCCM monitoring indicators with those We are anxious for the program and our low VHT- captured by the national HMIS can lead to chal- coverage does not stop us from embracing the program. lenges in monitoring important outcomes, such — DHT member, group interview, 2010 as disease trends and the contribution of CHWs in managing key illness. Such outcomes are crucial for identification of program needs, advocacy, budget allocation, and fundraising.34 DISCUSSION Furthermore, studies commissioned by the iCCM Implementing a well-functioning iCCM program task force in Africa and elsewhere emphasize the is an HSS intervention that touches on all areas need to develop a minimum set of essential indica- of the health systems framework including tors for iCCM at the national level.35 However, workforce development, establishment of com- generating these indicators would require closer munity information systems, service delivery, collaboration between MOH units, particularly and improvements in the procurement of medical those responsible for malaria and other infectious 28 supplies and technologies. Although we took an diseases and child health. Limited central-level fi- HSS approach as implementing partners, our find- nancing is likely to affect subsequent training ings show that iCCM implementation remained of VHTs and support supervision. The lack of largely noninstitutionalized into district-specific community-level accountability tools such as work plans. Specifically, there was neither evi- documents that clearly capture how medicines dence indicative of the integration of iCCM color- are transferred from health facilities and are coded medicines into health facility procurement subsequently distributed to specific VHTs is inher- supply chains nor the integration of budget lines ently connected to drug stocks at the community for training, supervision, and motivation of VHTs level. This finding has significant bearing given into district work plans. Only 1 district made the overwhelming body of evidence on the nega- significant strides in achieving district-led iCCM tive effects of drug stock-outs on the motivation of implementation by ensuring a functioning pro- VHTs in Uganda.36–38 Thus, current recommenda- curement and supply chain for iCCM medicines tions arising from WHO consultation meetings and supplies. and the general literature on iCCM discourage im- Perceived barriers to institutionalization of plementation of community programs in silos by iCCM at both the district and national levels in- requiring that primary health care strengthening cluded lack of proper stewardship on how to programs target both community and the higher Lack of transition from nongovernmental organization to levels of care.39–41 community-level district-led implementation, lack of agreement of Within Uganda’s decentralized health system, accountability national guidelines on community-level drug dis- DHTs are more or less autonomous segments of tools to capture tribution and poorly established community-level the national health system, consisting of all recog- how medicines are accountability systems, lack of integration of some nized health sector actors whose activities should distributed to of the iCCM indicators in the national HMIS, lack be reflected in the district health plan.18 The VHTs contributes of integration of iCCM medicines into the national MOH has the role of a principal agent with the to drug stock drug supply chain, limited funding from the cen- mandate to encourage local institutions, such as levels. tral government, and the lack of agency (capacity the DHTs, to make choices that achieve the

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objectives of the national health system. Such coordination. Cooperation between the DHT and obligations include the monitoring of local officials other local government administrative structures and the use of incentives and rules to shape local led to the establishment of a local accountability decisions.16 Likewise, at the local level, DHTs are procurement system for iCCM medicines. The in- supposed to have a decision space that allows novative collaborative efforts increased communi- them to make a range of choices regarding the ty acceptance and ownership of the program. The operation of health services within the district example is a typical demonstration of the effects of health system. Among other things, the custodial context factors outside the health system (such as roles of DHTs include planning for and manage- political leadership) on implementation of health ment of health services delivery in addition to interventions.12 implementation of policies. However, the effec- Moving forward, we concur with the wider in- tiveness of the decision-making powers given to stitutionalizing community health body of prac- DHTs with respect to iCCM also depends on indi- tice recommendations stipulating that country vidual and institutional capacities provided by the expansion of iCCM programs in the hard-to- MOH through provision of guidelines and train- reach areas where they are most needed, among ing. This is important as a couple of studies have other things, requires tackling persistent chal- demonstrated that synergy between decision space, lenges to institutionalization of iCCM that have capacity, and accountability promotes good deci- been identified over the years. Such challenges in- sion making at lower levels of decentralized sys- clude but are not limited to ineffective designing of tems.42 Given their perceived decision-making national and local policies that are not based on power, local authorities may make innovative the best available evidence, ineffective drug choices that are different from the directed change supply chains, and insufficient supervision and that the MOH imposes on them through its central motivation of CHWs.47 It is also a generally recom- authority.16 However, our findings are in concor- mended good practice that local communities dance with other studies, suggesting that poorly co- (such as DHTs and the people they serve) should ordinated policies within decentralized health be engaged in the designing of health interven- systems tend to render themselves to different tions and implementation approaches at an early interpretations based on perceived agency.43 The stage. Community engagement should be comple- findings are also indicative of a general perceived mented with strengthened collaboration between lack of empowerment (in terms of clarity of the national and local health systems and implement- boundaries of power entrusted to them and avail- ing partners to enhance local ownership and effec- able implementation tools) among DHTs with re- tive institutionalization of iCCM. This kind of spect to making innovative locally beneficial approach will foster the development of country- decisions around the institutionalization of iCCM. and district-specific work plans addressing priority This was regardless of the fact that we had used an issues while harmonizing donor support around HSS approach to implementation. The perceived the issues.47 lack of agency among DHTs as opposed to the initial Finally, empowerment of DHTs requires ca- perceived readiness points to factors within the pacity building in terms of provision of necessary wider health system that are sometimes beyond training, delegation of power, and provision of the DHTs’ control such as conflicting national tools and technologies for implementation of guidelines and limited central funding.44,45 The iCCM from central government authorities. Lack reported decision-making capacity gap has also of necessary implementation tools and account- been observed in other studies.23,46 For example, a ability mechanisms is inherently known to affect study by Alonso-Garbayo et al (2017) described the the degree of exercising decision space.43,48 This varying levels of agency exhibited by district au- will subsequently enhance their performance and thorities as (1) often operating within close bound- thus effectiveness in the institutionalization of aries defined by public policy, (2) occasionally government initiatives at the local district level. making decisions beyond their conferred authority From the implementing partner perspective, it is in some management domains, and (3) not being essential to have clear plans to ensure smooth able to use all decision-making powers allocated to transitioning from partner-supported programs to them in other domains.46 fully institutionalized and locally run programs We identified some of the enabling factors right from the onset of program implementation. for institutionalizing iCCM as illustrated by Subsequently, necessary steps must be taken the district that showed evident progress, inclu- to ensure a phased exit while strengthening ded a strong sense of autonomy, leadership, and DHTs and national government to take complete

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ownership for the financing and management of clearly outlined handover and exit plans. iCCM programs. Progressively, Uganda has devel- Collaboration between various administrative, oped a community health roadmap and several political, and community sectors is necessary guidelines have been harmonized since our study to build effective well-institutionalized systems. was conducted. We recommend further research Central to prompt and effective integration of na- to assess program maturity under these new tional iCCM policies into district health manage- circumstances. ment systems is the need for the MOH to provide sufficient leadership in terms of strategic policy di- Limitations rection formulation, ensure capacity building for This study has some limitations. Given that the DHTs through training and provision of adequate sample districts are all from mid- and central- tools for implementation, and establish sustain- western Uganda, the study findings may not nec- able partnerships with government and non- essarily be generalizable elsewhere. Our study governmental organizations working with iCCM. only assessed readiness from the perspective of the DHTs using the health systems framework Acknowledgments: We wish to acknowledge the inSCALE study country team and the inSCALE study group. without making objective system-wide readiness assessments. However, to the best of our knowl- Competing interests: None declared. edge, there were no specific iCCM program effec- tiveness assessment tools at the time of our study. Several tools that can be used to assess the readi- REFERENCES 1. Requejo JH, Bryce J, Barros AJ, et al. 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12. Paina L, Peters DH. Understanding pathways for scaling up health Uganda. Am J Trop Med Hyg. 2012;87(5 Suppl):97–104. CrossRef. services through the lens of complex adaptive systems. Health Policy Medline – Plan. 2011;27(5):365 373. CrossRef. Medline 30. Gilson L, ed. Health Policy and System Research: A Methodology 13. Amouzou A, Hazel E, Shaw B, et al. Effects of the integrated com- Reader. Geneva: World Health Organization; 2013. munity case management of childhood illness strategy on child mor- 31. Amouzou A, Kanyuka M, Hazel E, et al. Independent evaluation tality in Ethiopia: a cluster randomized trial. Am J Trop Med Hyg. of the integrated community case management of childhood – 2016;94(3):596 604. CrossRef. Medline illness strategy in Malawi using a national evaluation platform 14. Collins C, Green A. Decentralization and primary health care: some design. Am J Trop Med Hyg. 2016;94(3):574–583. CrossRef. negative implications in developing countries. Int J Health Serv. Medline 1994;24(3):459–475. CrossRef. Medline 32. Daelmans B, Seck A, Nsona H, Wilson S, Young M. Integrated com- 15. Gilson L, Mills A. Health sector reforms in sub-Saharan Africa: les- munity case management of childhood illness: what have we – sons of the last 10 years. Health Policy. 1995;32(1-3):215–243. learned? Am J Trop Med Hyg. 2016;94(3):571 573. CrossRef. CrossRef. Medline Medline 16. Jeppsson A, Östergren P-O, Hagström B. Restructuring a 33. Marsh DR, Tesfaye H, Degefie T, et al. Performance of ’ ministry of health–an issue of structure and process: a case study Ethiopia s health system in delivering integrated community- – from Uganda. Health Policy Plan. 2003;18(1):68–73. CrossRef. based case management. Ethiop Med J. 2014;52 Suppl 3:27 35. Medline Medline 17. Republic of Uganda Ministry of Health About Ministry of Health. 34. Mamo D, Hazel E, Lemma I, Guenther T, Bekele A, Demeke B. Ministry of Health Uganda webpage. 2020. Accessed February 13, Assessment of the monitoring and evaluation system for integrated community case management (iCCM) in Ethiopia: a comparison 2020. https://www.health.go.ug/about-moh/ against global benchmark indicators. Ethiop Med J. 2014;52:119– 18. Tashobya CK, Ssengooba F, Cruz VO, eds. Health Systems Reforms 128. Medline in Uganda: Processes and Outputs. Kampala, Uganda: Institute 35. Roberton T, Kasungami D, Guenther T, Hazel E. Monitoring iCCM: a of Public Health, Makerere University and Health Systems feasibility study of the indicator guide for monitoring and evaluating Development Programme, London School of Hygiene & Tropical integrated community case management. Health Policy Plan. Medicine. 2006. 2016;31(6):759–766. CrossRef. Medline 19. Barker PM, Reid A, Schall MW. A framework for scaling up health 36. Banek K, Nankabirwa J, Maiteki-Sebuguzi C, et al. Community case interventions: lessons from large-scale improvement initiatives in management of malaria: exploring support, capacity and motivation Africa. Implement Sci. 2016;11:12. CrossRef. Medline of community medicine distributors in Uganda. Health Policy Plan. 20. Mangham LJ, Hanson K. Scaling up in international health: what are 2015;30(4):451–461. CrossRef. Medline – the key issues? Health Policy Plan. 2010;25(2):85 96. CrossRef. 37. Strachan DL, Kallander K, ten Asbroek AH, et al. Interventions to im- Medline prove motivation and retention of community health workers deliver- 21. Callaghan-Koru JA, Gilroy K, Hyder AA, et al. Health systems sup- ing integrated community case management (iCCM): stakeholder ports for community case management of childhood illness: lessons perceptions and priorities. Am J Trop Med Hyg. 2012;87 from an assessment of early implementation in Malawi. BMC Health (5 Suppl):111–119. CrossRef. Medline Serv Res. 2013;13:55. CrossRef. Medline 38. Strachan C, Wharton–Smith A, Sinyangwe C, et al. Integrated com- 22. Haines A, Sanders D, Lehmann U, et al. Achieving child survival munity case management of malaria, pneumonia and diarrhoea goals: potential contribution of community health workers. Lancet. across three African countries: a qualitative study exploring lessons 2007;369(9579):2121–2131. CrossRef. Medline learnt and implications for further scale up. J Glob Health. 2014;4 (2):020404. CrossRef. Medline 23. Martineau T, Raven J, Aikins M, et al. Strengthening health district management competencies in Ghana, Tanzania and 39. Nanyonjo A, Counihan H, Siduda SG, Belay K, Sebikaari G, Uganda: lessons from using action research to improve health work- Tibenderana J. Institutionalization of integrated community case force performance. BMJ Glob Health. 2018;3(2):e000619. management into national health systems in low- and middle-income CrossRef. Medline countries: a scoping review of the literature. Global Health Action. 2019;12(1):1678283. CrossRef. Medline 24. Republic of Uganda Ministry of Health (MOH). Village Health Team Strategy and Operational Guidelines. Kampala: MOH; 40. World Health Organization. Technical consultation on 2010. institutionalizing Integrated Community Case Management to end preventable child deaths. https://www.who.int/malaria/mpac/ ’ – 25. World Health Organization (WHO). Everybody s Business mpac-october2019-session6-institutionalization-of-iCCM.pdf. ’ Strengthening Health Systems to Improve Health Outcomes: WHO s Published July 2019. Accessed January 20, 2020. Framework for Action. Geneva, Switzerland: WHO; 2007. https:// www.who.int/healthsystems/strategy/everybodys_business.pdf 41. Yourkavitch J, Davis LM, Hobson R, et al. Integrated community case management: planning for sustainability in five African countries. J 26. Republic of Uganda Ministry of Health (MOH). Integrated Glob Health. 2019;9(1):010802. CrossRef. Medline Community Case Management of Malaria Pneumonia and Diarrhea, 42. Liwanag HJ, Wyss K. Optimising decentralisation for the health sec- Implementation Guidelines. Kampala: MOH; 2010. tor by exploring the synergy of decision space, capacity and ac- 27. Republic of Uganda Ministry of Health (MOH), USAID. Supply Chain countability: insights from the Philippines. Health Res Policy Syst. Systems for Community Health Programs in Uganda: Situation 2019;17(1):4. CrossRef. Medline Analysis. Kampala: MOH; 2016. 43. Henriksson DK, Ayebare F, Waiswa P, Peterson SS, Tumushabe EK, 28. McGorman L, Marsh DR, Guenther T, et al. A health systems ap- Fredriksson M. Enablers and barriers to evidence based planning in proach to integrated community case management of childhood ill- the district health system in Uganda; perceptions of district health ness: methods and tools. Am J Trop Med Hyg. 2012;87(5 Suppl):69– managers. BMC Health Services Research. 2017;17(1):103. 76. CrossRef. Medline CrossRef. Medline 29. Nanyonjo A, Nakirunda M, Makumbi F, Tomson G, Källander K, 44. Republic of Uganda Ministry of Health (MOH). Overview of The inSCALE Study Group. Community acceptability and community health system and scale up plan. Kampala: MOH; adoption of integrated community case management in 2020.

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45. Republic of Uganda Ministry of Health (MOH). VHT/Community 48. KirungaTashobya C, Ssengooba F, Nabyonga-Orem J, et al. A cri- Health Extension Workers. Kampala: MOH; 2019. tique of the Uganda district league table using a normative health system performance assessment framework. BMC Health Serv Res. 46. Alonso-Garbayo A, Raven J, Theobald S, Ssengooba F, Nattimba 2018;18(1):355. CrossRef. Medline M, Martineau T. Decision space for health workforce management in decentralized settings: a case study in Uganda. Health Policy Plan. 49. Ballard M, Bonds M, Burey J, et al. Community Health Worker 2017;32(suppl_3):iii59–iii66. CrossRef. Medline Assessment and Improvement Matrix (CHW AIM): Updated Program 47. Kagwa P, Chambert E. Partnering to strengthen community health in Functionality Matrix for Optimizing Community Health Programs. Uganda. Presentation presented at: Institutionalizing Community Health Washington, DC: USAID; 2018. https://www.chwcentral.org/ Conference; March 27–30, 2017; Johannesburg, South Africa. Accessed community-health-worker-assessment-and-improvement-matrix- January 22, 2020. https://ichc2017.mcsprogram.org/ chw-aim-updated-program-functionality

Peer Reviewed

Received: September 15, 2019; Accepted: March 4, 2020

Cite this article as: Nanyonjo A, Kertho E, Tibenderana J, Källander K. District health teams’ readiness to institutionalize integrated community case management in the Uganda local health systems: a repeated qualitative study. Glob Health Sci Pract. 2020;8(2):190-204. https://doi.org/10.9745/ GHSP-D-19-00318

© Nanyonjo et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https:// doi.org/10.9745/GHSP-D-19-00318

Global Health: Science and Practice 2020 | Volume 8 | Number 2 204 ORIGINAL ARTICLE

Scaling Up Access to Implants: A Summative Evaluation of the Implants Access Program

Rebecca Braun,a Annika Grevera

Key Findings ABSTRACT The Implants Access Program (IAP) was a partnership between The Implants Access Program increased access to public and private organizations that aimed to increase access implants by: to contraceptive implants for women in low-income countries. The partnership began with 2 volume guarantee agreements n Devising an innovative solution to address price that reduced the price of implants by approximately 50% and barriers was complemented by efforts to address supply chain, service n Enhancing supply chain data visibility and delivery, and knowledge and awareness barriers. We con- coordination to limit stock-outs ducted a summative evaluation to identify key insights related to the IAP’s relevance, effectiveness, and sustainability. We n Leveraging existing delivery capacity and completed a desk review of program materials and published strengthening capacity in targeted areas literature, followed by 42 in-depth interviews, including global n Coordinating global and country-level stake- stakeholders and country stakeholders in 3 case example coun- holders to address key challenges tries: Kenya, Nigeria, and Uganda. The evaluation found evi- dence of increased access to implants including a 10-fold Key Implications increase in procurement between 2010 and 2018 and an in- crease in prevalence of contraceptive implants during this same period. The IAP leveraged global family planning efforts n Donors, policy makers, and implementing taking place at the time, and its partnerships offered a business partners should align method-specific efforts to case for manufacturers to support increased access to implants. support broader family planning goals and im- Enhanced supply chain visibility and coordination helped limit plementation plans at the global and country country-level stock-outs, and the IAP built on existing in-country level. delivery capacity. Although the IAP was able to address key n Donors should engage private-sector manufac- challenges due to its effective collaboration and coordination turers to identify mutually beneficial opportunities at global and country levels, sustaining progress requires insti- for collaboration to address price barriers. tutionalized mechanisms to continue global efforts and long- term assurances that the low price of implants will be main- n National stakeholders and implementing partners tained. Over 6 years, the IAP supported tremendous progress should prioritize efforts to improve supply chain in increasing access to implants for women in low-income coun- visibility, increase efficiency and sustainability of tries by building a public- and private-sector collaboration that provider training, and support community focused on systems change in the family planning field. This sensitization and awareness raising to ensure partnership matched a unique response to a unique problem: clients can exercise free and informed building tools, systems, and capacity that can inform and sup- contraceptive method choice. port the introduction and scale-up of new and underutilized contraceptive methods.

BACKGROUND which include implants and intrauterine devices (IUDs), t the London Summit on Family Planning in 2012, presented a critical opportunity to support global efforts to reach this goal.2 In the few years before 2012, overall leaders across the globe committed to providing ac- A demand for implants began to increase significantly in cess to modern contraception to 120 million additional developing countries,3 yet barriers to access remained, women who want to prevent or delay pregnancy in including high cost of commodity, few trained providers, ’ 1 – 69 of the world s poorest countries by 2020. Increasing and limited supply.4 6 access to long-acting reversible contraceptives (LARCs), To make contraceptive implants more available to women in the world’s poorest countries, a group of pub- a Global Impact Advisors, San Mateo, CA, USA. lic and private organizations, including the Bill & Correspondence to Annika Grever ([email protected]). Melinda Gates Foundation; the Clinton Health Access

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Initiative (CHAI); the governments of Norway, Overall, the IAP successfully contributed to Sweden, the United Kingdom, and the United increased access to implants among women in States; and the Children’s Investment Fund supported countries. Procurement and use of Foundation, with support from the United implants were used as proxies for access for the Nations Population Fund (UNFPA), formed the purpose of this evaluation. Annual procurement Implants Access Program (IAP) in 2013.7 The IAP of implants for the world’s 69 poorest countries partners sought to increase access to implants by (i.e., FP2020 focus countries) increased 10-fold, addressing key barriers at the global and country from 1.7 million units in 2010 to 10.8 million units level (Table 1). Specifically, the IAP supported a in 2018 (Figure 1),9 without evidence of over- multipronged effort starting with volume guaran- stocking.10 The agreed-upon price reductions en- tee (VG) agreements with 2 pharmaceutical man- abled more than $500 million in cost savings ufacturers that reduced the price of commodities when compared to the cost of procurement at the by approximately 50%. The 2 VGs were backed previous price.11 Moreover, contraceptive implant by the Bill & Melinda Gates Foundation, the gov- prevalence dramatically increased during that ernments of Norway and Sweden, and the time. A recent analysis of contraceptive implant Children’s Investment Fund Foundation, who use across 12 sub-Saharan African countries dem- agreed to annual minimum purchase volumes onstrated that prevalence rates increased from an that would be met at the reduced price.8 These average of 1.9% across surveys between 2008 and funders partnered with a broader donor group in- 2013 to an average of 8.1% across surveys be- cluding the funders who procure the majority of tween 2015 and 2017.5 Further, in 11 of the contraceptive commodities for FP2020 countries. 12 sub-Saharan countries with data available The reduced commodity price was available to en- from multiyear national surveys, implants use tities serving the poorest women, including gov- was the primary factor contributing to increases ernments in FP2020 countries, donors who in modern contraceptive prevalence rates be- procured for public-sector or social marketing or- tween 2003 and 2017, providing a greater contri- ganization (SMO) delivery in these countries, and bution than all other modern methods (e.g., pills, some nongovernmental organization/SMO pro- injectables and intrauterine devices) combined.5 grams. The price agreements were complemented The IAP established a governance structure to by efforts to address supply chain, service delivery, coordinate activities and enable information shar- and knowledge and awareness barriers.6 ing (Figure 2). This included the guarantee group,

TABLE 1. Implants Access Program Objectives, Barriers Addressed, and Partner Approaches

Objectives Barriers Addressed Partner Approaches

1. Improve market dynamics  High unit price of the primary LARC  Volume guarantee to lower price of implants demanded in FP2020 countries  Support for market entry of a generic implant product 2. Strengthen supply chain performance  Limited and inconsistent information on  Improvements to data visibility, transparency, country procurement needs and supply and coordination to better match country- availability level supply and demand  Inconsistent supply availability at service  Introduction of dashboards and job aids to delivery points strengthen and support in-country supply chain efforts 3. Improve and expand service delivery  Shortage of trained providers to insert  Creation and expansion of innovative and and remove implants cost-effective training approaches  Expansion of the range of service delivery models to provide LARCs 4. Increase knowledge and awareness  Limited knowledge among women about  Community awareness and sensitization family planning options including activities to increase understanding of family implants planning and benefits of LARCs 5. Together, the strategies above contributed to a fifth objective: Improve the enabling environment for contraceptives

Abbreviation: LARC, long-acting reversible contraceptive.

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FIGURE 1. Implant Procurement for FP2020 Countries, 2010–2018a

12 10.8

10

8.1 8 6.7 6.0 6 5.5 4.8 3.9 4 Implants procured (millions) 1.7 1.7 2

- 2010 2011 2012 2013 2014 2015 2016 2017 2018 Year a These data were sourced from United Nations Population Fund Reproductive Health Interchange on July 1, 2019. Data are provided by the central procurement offices of large family planning donors, institutional buyers, and other organizations that procure contracep- tives. The data reflect 80% of donor-provided contraceptive supplies and do not include directly procured products by governments. More information is available at: https://www.unfpaprocurement.org/rhi-home. a forum for high-level decision making as well as Evaluation Objectives issue discussion and resolution, and 2 oversight The objective of this evaluation was to understand boards that engaged each of the 2 World Health the IAP partnership’s contribution toward achiev- Organization (WHO) prequalified implant manu- ing increased access to implants, including suc- facturers. The partnership evolved to include a cesses and challenges that were faced, and to secretariat and was supported by 2 additional identify lessons from the program that could in- groups that focused on country-level needs: the form future efforts to introduce and scale new Operations Group and the coordinated supply and underutilized contraceptive products. We se- planning (CSP) group, that had been initiated pri- lected an evaluation framework based on the or to the IAP in 2012 as a workstream of the Organisation for Economic Co-operation and Deve- Reproductive Health Supplies Coalition (RHSC). lopment’s Development Assistance Committee The CSP group aims to prevent family planning criteria, focusing on relevance, effectiveness, and commodity stock imbalances by using shared sup- sustainability. ply chain data and information to coordinate ship- Accordingly, this study aimed to evaluate the ments and the allocation of commodities within extent to which the IAP responded to the needs and among countries. At the country level, IAP of the family planning community, understand ’ partners provided targeted funding and technical progress toward IAP s original objectives and oth- support for scale-up efforts through implementing er unexpected outcomes, and identify the critical organizations working with public and private sec- factors as well as risks to sustaining its achieve- tors, including CHAI, EngenderHealth, Jhpiego, ments at both global and country levels. and John Snow, Inc. (JSI), as well as through SMOs, including Marie Stopes International and METHODS Population Services International. We conducted a summative evaluation from The Operations Group was formed in 2015 in January to June 2019. We started with a desk re- This study response to the need for coordination and support view of background materials and other relevant evaluated the to countries with the transition from Implanon documents to provide a deeper understanding of IAP’s relevance Classic to Implanon NXT. This group supported the IAP and guide the key informant interviews. and effectiveness coordination and communication around global Documents included internal reports and formal and identified key and country-level investments in training and ser- meeting summaries produced by IAP partners, risks to sustaining vice delivery. published peer-reviewed and gray literature, and progress.

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FIGURE 2. Implants Access Program Governance Structure

Guarantee Group •The Operations Group and Comprised of donors/procurers, supply group representative, and secretariat Coordinated Supply Planning Group focus on Key functions: forum for collaboration, information country-specific needs sharing, monitoring progress, and issue resolution Secretariat •The Guarantee Group and Supported by Global Impact Advisors (GIA) Oversight Board provide forums for high-level Key functions: facilitating communication, project management and cross-partnership strategic decision making coordination Oversight Board and issue resolution Comprised of donors, procurers, supply group, and manufacturers

Key functions: forum for monitoring progress, issue discussion, and resolution with manufacturers

Operations Group Coordinated Supply Planning Group Comprised of donors and implementing partners Comprised of technical assistance partners and procurers with input from manufacturers (Workstream of RHSC) Key functions: address in-country operational concerns and implementation questions Exchange information on Key functions: monthly procurement reporting and supply in-country supply needs chain analyses

notes from interviews with IAP partners recommendations are a synthesis of the desk re- conducted in 2017 as part of a sustainability view and interview findings. assessment. After the desk review, we conducted 3 rounds of semistructured in-depth qualitative interviews RESULTS with 42 stakeholders to answer our questions at The findings that emerged from the IAP evalua- tion identify factors that contributed to success, global and country levels and to identify specific challenges that were faced and overcome, as well in-country examples. The first round of 12 inter- as challenges that continue to limit progress to- views included donors, manufacturers, procurers, ward improving access to implants. The findings and technical assistance providers who could are framed as 6 key insights related to relevance, provide a global perspective on the IAP. The sec- effectiveness, and sustainability that can inform ond round of 10 interviews included implement- future efforts to introduce and scale new and ing partners who could provide a multicountry underutilized contraceptive products (Figure 3). perspective. The third round of 20 interviews included Ministry of Health (MOH) representa- tives, procurers, and implementing partners in Relevance 3 case-example countries—Kenya, Nigeria, and 1. Increased Access to Implants The IAP leveraged global family planning atten- Uganda—that were cited most frequently during tion and efforts and recognized an opportunity the second round of interviews. Participants in for LARCs and implants specifically. This broader round 1 were selected purposively, and rounds framing and positioning represented a critical evo- 2 and 3 were selected via snowball sampling from lution of the partnership in response to concerns previous participants. Before interviews began, from the family planning community that the participants were informed that their identity efforts were focused on promoting a single meth- would remain anonymous, and specific quotes od category. would be anonymized. The timing of the IAP’s launch aligned well Interviews were conducted via phone and ad- with global efforts initiated in 2012, including the ministered by the evaluation team. Separate semi- London Family Planning Summit, the formation structured interview guides were developed for of FP2020, and the United Nations Commission each round of stakeholder interviews. Detailed on Life-Saving Commodities for Women and notes were taken by the evaluation team during Children report. These efforts aimed to dramat- each interview; data were analyzed with an itera- ically increase global contraceptive access and tive, thematic approach. The key insights and options with accompanying new commitments

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FIGURE 3. Key Insights from the Implants Access Program Evaluation

RELEVANCE 1. Implants were the right product at the right price at the right time.

2. The multi-stakeholder partnership was built on established relationships and offered a business case for manufacturers to support increased access.

3. Enhanced supply chain data visibility and coordination limited stockouts but significant challenges remain requiring investment in systems and capacity. EFFECTIVENESS 4. IAP leveraged existing delivery capacity in countries and strengthened capacity in targeted areas.

5. Effective collaboration and coordination were critical at global and country levels to address key challenges in a timely manner and achieve impact.

6. Sustaining progress requires institutionalized mechanisms to continue global and country SUSTAINABILITY efforts and long-term assurances that the low price of implants will be maintained.

from donors and governments. The IAP leveraged identified as an underutilized commodity needing this global momentum and aligned with both the attention by the Caucus on New and Underused broader family planning ecosystem and emerging Reproductive Health Technologies as early as global family planning architecture in a way that 2011, further confirming the need for attention catalyzed action, as stakeholders could connect to this method category.12 the purpose of the program to the global family As a result, IAP partners came together around planning dialogue. an innovative solution to the price barrier through Interviewees noted that the many efforts and 2 VGs that would kickstart the implants market for events in the family planning field at this time FP2020 countries.6 At the country level, the global made it difficult to map clear causal linkages to at- momentum and accompanying donor and coun- tribute success. However, alignment with the try commitments to family planning goals were broader family planning ecosystem was seen as key factors that contributed to the success of the critical to success for the IAP. Throughout the IAP. By the end of 2013, 28 countries had made IAP’s lifespan, partners were able to draw on the commitments in support of FP2020. By 2018, momentum of the global family planning field, 11 countries had identified FP2020 commitments building on key events that expanded country that specifically referenced access to implants as and donor commitments to family planning part of expanding contraceptive method choice.13 (Table 2). Country-level interviewees noted that political The IAP also filled a key need identified by will toward family planning was critical to getting global partners to make LARCs, and specifically government stakeholders and other partners on implants, more available as part of a broader array board and aligned around a common plan to scale of contraceptive methods made routinely avail- up access to contraceptive methods, including able to clients in family planning programs. A implants. 2012 United Nations Commission on Life-Saving Ensuring that the IAP strategy aligned with the Commodities for Women and Children report broader family planning agenda to increase access Alignment with identified implants as one of 3 underutilized fami- to a full contraceptive method mix with informed the broader family ly planning products and identified the high price choice and quality service delivery was a key point planning as the key barrier to enable greater access to of alignment in the early phase of forming the ecosystem was implants.4 One interviewee noted that the link be- partnership. Although this was the approach seen as critical to tween the IAP and the commission’s recommen- from the outset at the country level, the global- IAP’ssuccess. dations was critical to making a case to donors to level framing and positioning of this initiative support the effort. Implants had also been within the broader family planning agenda was

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TABLE 2. Key Events in the Global Family Planning Field, 2012–2018

Event Year Objective Relevance to Implants Access Program

London Family Planning 2012 This summit secured US$2.3 billion toward meeting Countries made specific goals around raising Summit the unmet need for contraception for 120 million modern contraceptive prevalence rate and reduc- women worldwide by 2020. ing unmet need; donors committed funding for family planning commodities and service delivery, including implants. FP2020 launch 2012 This global partnership of governments, donors, FP2020 connected countries committed to LARCs civil society organizations, and technical experts with financial and technical resources as needed. emerged to help meet the goals of the 2012 London summit. UN Commodities 2012 This report listed 13 lifesaving commodities that Implants were named as a lifesaving commodity Commission report could save over 6 million lives and avert maternal and this report identified recommendations to im- deaths via improved access to family planning. prove financing, utilization, supply, and demand for implants. UNICEF RMNCH Trust Fund 2013 This fund was established by UNICEF, UNFPA, and The RMNCH trust fund supported eight countries WHO to finance high-impact interventions in as they expanded the availability of implants and RMNCH based on recommendations of the UN other lifesaving commodities. Commodities Commission report. WHO task shifting 2013 The WHO published updated, evidence-based The updated task shifting recommendations speci- recommendations recommendations on the provision of RMNCH fied that auxiliary nurses and auxiliary nurse mid- interventions by different cadres of health workers. wives should be permitted to insert and remove implants with targeted monitoring and evaluation. WHO expansion of implants 2015 The fifth edition of WHO’s Medical Eligibility Postpartum women had more options for hormon- eligibility criteria Criteria reduced restrictions around the use of al contraceptives, which enabled the opportunity implants and other hormonal contraceptives for to provide LARCs to women shortly after birth. adolescents and breastfeeding women less than 6 Adolescents were cleared to access implants. weeks’ postpartum. Youth statement on LARCs 2015 This statement provided evidence that LARCs were The document provided guidance for programs safe for youth and adolescents and was signed by and service providers that all adolescents and over 50 endorsing organizations. youth deserved access to a full range of methods, including implants. 2017 Family Planning 2017 Donors, policymakers, and advocates convened to Countries, donors, civil society organizations, and Summit assess efforts toward reaching FP2020 goals and private sector partners recommitted to LARCs. accelerate progress. More than 2 dozen FP2020 countries committed to expanding their method mix.

Abbreviations: LARC, long-acting reversible contraceptive; RMNCH, reproductive, maternal, newborn, and child health; UN, United Nations; UNICEF, United Nations Children’s Fund; UNFPA, United Nations Population Fund; WHO, World Health Organization.

something that evolved during the initial years of policy change, provider training, and consumer the IAP and helped ensure the effort was not per- education. The manufacturer noted that this could ceived as a push from donors for a single contra- have an impact on the long-term sustainability of ceptive method. producing the product. Although all stakeholders agreed that a price reduction was necessary to unlock demand for implants, there were differing perspectives on Effectiveness whether the agreed price was the right price for a 2. Addressed Price Barriers long-term sustainable market. As a manufacturer The agreement to reduce prices, which was crucial representative explained, the significant reduction to the success of the IAP, was made possible in price and resulting low margin made it difficult through the development of strong personal rela- to garner their company’s support for investment tionships as well as underlying business funda- in manufacturing capacity and limited what they mentals. The IAP partnership sought to achieve a could provide in terms of support to countries for stable market for implants with sustained

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affordable prices through 2 VGs, building upon maintaining or improving utilization rates. previous price reduction efforts initiated by the Further, it was also viewed as a win for manufac- RHSC in 2010.14 The agreements made Bayer’s turers in terms of their contribution as part of cor- Jadelle and Merck’s Implanon (and later Impl- porate social responsibility and a source of pride anon NXT) available to women in the world’s for employees working on the product. The win poorest countries at price reductions of approxi- for procurers came from the lower price as well as mately 50% through 2018. The aim of the VGs coordination of orders that emerged from the was to increase confidence in long-term demand, partnership, allowing them to optimize allocation allowing manufacturers to make up-front invest- of available supply and maximize impact. The IAP ments that would lower costs and enable reduced was also described by manufacturers as a win for prices for years to come. women who would now have access to a modern The IAP also supported ongoing efforts to in- contraceptive method that previously had limited troduce a prequalified generic product, Dahua’s availability and access. Levoplant, in collaboration with DKT, to the One aspect of the reduced price agreement was market to increase competition and maintain the to remove most supports for provider training reduced price following the end of the price agree- that manufacturers had previously provided, ment. Prequalification of the generic product was such as training of master trainers or provision achieved in 2017 after nearly a decade of effort. of commodities for training (e.g., model arms IAP partners funded technical assistance to the ge- or placebo implants), thus transferring this finan- neric manufacturer and supported market entry cial responsibility to donors and governments. through coordinated efforts with countries to con- Manufacturers developed and shared global train- sider procurement of the product. All 3 case exam- ing materials which could be adapted to specific ple countries are planning to introduce Levoplant country contexts but, in general, did not provide as an alternative implant. However, several inter- additional supports. The exception was a limited view participants identified additional provider amount of support that was made available during training requirements as a barrier. the transition from Merck’s Implanon Classic to The reduced price achieved through the Implanon NXT. Global stakeholders identified the VGs was critical to scale up access to implants, shift in policy regarding training resources as a allowing existing procurement resources to challenge. There was limited visibility among all stretch further and dramatically increasing the partners into the resources that would be required number of implants procured for FP2020 to scale up training for providers as implants pro- countries between 2010 and 2018 (Figure 1). curement increased and how those costs would be Manufacturers have committed to maintaining covered. The transition to Implanon NXT com- the new price through 2023, after the VGs formal- pounded this problem with additional training ly ended in 2018. Whether the market has reached requirements. Providers who had already been an equilibrium point with sustainable pricing and trained in Implanon Classic required additional supply is yet to be determined and will require training for the updated insertion technology. continued monitoring over the coming years as This training had to be completed during a rela- the market stabilizes. The IAP’s engagement with manufacturers tively condensed period as the Implanon Classic was built from established relationships between was being phased out and replaced by NXT. The The IAP engaged procurers, donors, and manufacturers who had intensive resource requirements for this retraining with been working together for many years on a range effort fell largely on donors and governments. manufacturers by of family planning products. The VG was pre- building on sented to manufacturers as a business case with a 3. Enhanced Supply Chain Visibility and clear value proposition in terms of increased visi- Coordination relationships bility and stability of long-term demand that The IAP built capacity at both the global and coun- between would allow suppliers to produce higher volumes try level to address supply chain limitations and procurers, donors, at a lower price, while still covering their cost of limit stock-outs. Although significant challenges and goods. The agreement was described by a manu- remain requiring investment in systems and ca- manufacturers facturer representative as a “win-win for all pacity, the tools developed have been broadened who had worked partners engaged with the IAP.” The win for to additional products over time. together for many manufacturers was the assurance of sufficient de- To reduce inconsistency of supply availability years on a range mand (either from procurers or guarantors) to at the global and country level, the IAP sought to of family planning ramp up production and expand capacity while improve both the quality and visibility of the products.

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demand pipeline through a mechanism to support Similarly, as part of overall capacity building procurer and manufacturer coordination and im- efforts, implementing partners also developed prove associated data. The RHSC’s CSP group job aids and training for commodity managers addressed this need, mitigating the risk of market to improve supply planning, and trained health disruptions related to the price reduction, such as care providers on the importance of data and the potential for overordering and stockpiling of reporting to improve supply availability. Imple- the commodity or identifying where additional menting partners often filled gaps in supply chain funding was needed for procurement to support systems by facilitating communications between rapidly growing demand. Through the IAP agree- warehouses and supporting alternate distribution ments, manufacturers shared all procurement channels to get products to service delivery data with JSI on a monthly basis to monitor prog- points, but these measures were described by ress to goals and identify imbalances between sup- interviewees as stopgap measures as opposed to ply and demand. The CSP group contributed to sustainable systems improvements. Although IAP The CSP group IAP’s effectiveness and brought together key sta- partners did provide technical assistance to indi- brought together keholders who could review shared data on coun- vidual countries and in regional workshops, ca- key stakeholders try orders and stocks on hand, identify supply pacity for national supply planning remains a to review shared issues that arose, and quickly coordinate action barrier to achieving the forecast accuracy needed data on country in response. As a manufacturer representative to ensure supply availability and maintain optimal orders and stocks, explained: national supply levels. identify supply CSP group changed interactions. Organizations are now Overall, the most frequently cited challenge issues, and talking to each other, [about] who is delivering what to across country-level interviewees was supply coordinate a ’ each country, and now they re able to go into the field to shortages at both the national level and service de- response. get a clearer picture, and get more insight into the livery points. Despite some improvements in ca- [demand] forecast. pacity for national supply planning, as well as in- According to unpublished CSP data from JSI, country supply chain management, interviewees the CSP coordination in 2018 resulted in recom- in the 3 case example countries noted a remaining mended actions that avoided national stock-outs need for overall system strengthening efforts to and/or shortages of implants in 24 countries, total- improve family planning supply chains and re- ing an additional 7.5 million couple years of pro- duce shortages at service delivery points, as well tection and averting approximately 1.8 million as addressing global shortages that have resulted 15 unintended pregnancies. The effectiveness of in stock-outs at central warehouses. CSP was demonstrated early on and the scope quickly expanded to support multiple family plan- ning products. 4. Leveraged Existing Service Delivery Capacity At the country level, partners developed fami- The IAP leveraged existing service delivery capac- ly planning dashboards to integrate data across ity investments in training, expanded delivery service delivery, consumption, and training data- models, and conducted community awareness bases to improve supply availability by targeting and sensitization activities from participating available and appropriate commodities at facilities organizations. These investments, while valuable with trained providers, building off of longstand- and important to the success of the IAP, were not ing supply strengthening efforts in the family wholly sufficient and gaps remain. planning field. The dashboards used in Nigeria MOH stakeholders in each country coordinat- and Kenya were created initially in support of ed with donors and implementing partners to implants scale-up efforts, specifically around the align around national goals and implementation transition to NXT. As capacity to use these analyt- plans to scale up LARCs, including implants. ical tools increased, the dashboards were expand- These plans in most countries reflected broader ed to cover all family planning methods in both family planning commitments and formed part of countries. The dashboards offered data visibility national costed implementation plans to achieve to stakeholders that previously did not have access family planning goals. Thus, the IAP was able to to all the data in an integrated manner. Although align strategically to leverage existing in-country the dashboards improved implant supply avail- capacity and expertise to expand access to family ability and had important benefits for other family planning. planning products as well, they did not solve the Leveraged Best Practices in Training. supply chain challenges. Improved approaches were needed to achieve

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training goals with limited available resources, es- successful experiences in countries that had pecially during the introduction of NXT and implemented task sharing policies as a means of phaseout of Implanon classic. IAP partners tested increasing access to family planning. All 3 focus various training models, identifying appropriate countries considered opportunities for task shar- cost-effective solutions that combined on-the-job ing of implants delivery, but barriers in Uganda Cost-effective training with follow-up supportive supervision, and Kenya, particularly resistance from higher- solutions mentoring, and coaching. These approaches level health care workers, have prevented policy combined on-the- were feasible as the updated product required change. Kenya allows insertion by nurses and job training with minimal differences in insertion techniques and midwives but has faced resistance when consider- follow-up no substantial changes to patient counseling ing policy change to allow insertions by communi- supportive procedures.16 Interviewees estimated that these ty health workers. Uganda has supported task supervision, approaches reduced training costs by up to sharing to allow nurses and midwives to perform mentoring, and 60% when compared to traditional in-service insertions in policy documents, but they do not coaching. training models. The approaches also improved yet have legal protection to do so.18 In 2014, providers’ competency to perform implant Nigeria successfully approved a task shifting policy insertions and removals by allowing more oppor- allowing community health extension workers tunities to practice and maintain skills and estab- (CHEWs) to insert and remove implants. The cur- lishing mechanisms for continued supportive rent status of national scale-up efforts to train supervision. The on-the-job training approach CHEWs in implants insertions and removals in also minimized disruption of health service provi- Nigeria could not be confirmed for this evaluation. sion that often results from off-site training. IAP As one implementing partner in Nigeria partners shared these best practices in training explained: innovations through the Operations Group, en- abling widespread dissemination across country Changing the task shifting policy was a challenge, our partners in a timely manner. nurses and midwives feel this was a duty for [they them- Country stakeholders identified several key selves]to provide so they were against it [task shifting to challenges related to provider training, including CHEWs] initially. However, we navigated through this maintaining high-quality counseling and mini- by having an acceptable training manual for the entire mizing bias toward provision of specific methods, health care system, which gave some level of comfort of including implants. To overcome these challenges, any system we put in place. We also did a cost-benefit ongoing embedded mentoring and coaching mod- analysis and a big review of human resources for health els were designed to reinforce training messages and found that majority of health care workers were of- and improve quality counseling; however, these ten CHEWs, so it prompted a conversation, that com- models do require ongoing resources to maintain bined with data, was very successful. their efficacy. Interviewees also identified a persis- Implant availability in private sector for-profit tent system-wide challenge of retaining trained facilities has not experienced the same growth providers in contexts of high turnover of health seen in the public sector.19 Interviewees in the personnel. 3 case example countries noted this as a challenge Expanded Service Delivery Models. to increasing access to implants. The price agree- Although some countries utilized outreach ser- ment applies to procurers purchasing for public vices and liberalized task sharing policies to ex- sector delivery and delivery through SMOs who pand access, other countries relied on their could charge a maximum fee for the product. existing delivery capacity. Private for-profit providers cannot purchase im- Outreach events and mobile clinics, serving plant commodities at the reduced price agreed to high volumes of clients seeking family planning through the VGs. The higher price for these provi- services, provided training opportunities for pro- ders combined with competition with typically viders while also offering family planning access free or reduced-cost provision of implants in the to women in remote areas where distance to public sector could undermine any financial in- clinics can pose a significant barrier. centive for these providers to offer implants. The 2012 WHO task sharing recommenda- Without sustainable mechanisms for private for- tions17 identified opportunities for expanding the profit providers to purchase at affordable prices, cadre of health workers that could provide implants likely will not reach women through implants and other family planning methods. these channels. In Nigeria, nearly 60% of women These recommendations built from prior access family planning through private medical

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sources,20 making access to the lower priced prod- to implants removal services was not a focus of ini- uct for these providers an important factor to con- tial IAP efforts, but over time, programmatic con- tinue progress in increasing access to implants. cerns about barriers to accessing removal services Conducted Community Awareness and was escalated through the Operations Group. In Sensitization Activities. Demand generation response to this growing need, the IAP developed was not an explicit objective of the IAP as there an Implants Removals Task Force in 2014 to coor- was an underlying assumption from the outset of dinate efforts and provide programmatic guid- latent demand for the method based on early ance. This group identified standards that needed experiences with introduction of free or highly to be in place to assure quality removal services.21 subsidized implants.3 However, although country- As another example, working together with levelpartnersfoundthatuptakewashighassoon the 2 manufacturers and key procurers, the IAP as providers were trained in some areas, they found Operations Group supported the development of low utilization and uptake in other areas. In general, standardized packaging, as opposed to customized partners found that the information and awareness packaging by procurer, for both implant products. gaps were around the benefits of family planning This simplified packaging was a critical component more broadly rather than implants specifically. for suppliers to meet the reduced price commit- Implementing partners were able to address these ment, and at the same time, improved supply gaps through general information and communica- chain performance by allowing manufacturers to tion efforts about family planning with an emphasis build up inventory without the need for custom- on the benefits of LARCs. These activities across the ized packaging by procurer. Further, in 2015, sev- 3 case example countries used community health eral IAP partners, including UNFPA and CHAI, workers for knowledge and information sharing, as collaborated to develop a standardized consum- well as traditional and social media and mobile ables kit that combined the necessary supplies re- phone-based platforms. For example, successful ac- quired for both implant insertion and removal. tivities were tailored to target audiences inclusive of According to interviewees, the collaboration male community members; religious, government and coordination among partners at the global and political leaders; health facility workers beyond level also contributed to coordination among part- service providers; and women in the community. ners at the country level. Coordination efforts led by government stakeholders that brought togeth- 5. Encouraged effective global and country-level er the MOH, donors, implementing partners, collaboration and coordination SMOs, and the private sector around national The IAP used a Coordination at the global and country level was scale-up plans were identified as a key success fac- formal, agile, and an effective element of the IAP from the begin- tor across case example countries. This coordina- responsive ning. However, challenges arose in aligning tion was important at both the national and governance around goals and commitments particularly as dif- subnational levels and served to strengthen efforts structure that was ferent partners were engaged at different levels and minimize duplication across family planning critical to and different phases over time. The IAP coordinat- programs. successfully ed global stakeholders through a formal gover- However, the partnership also faced key chal- achieving nance structure that facilitated information lenges in terms of accountability and commit- implants scale-up sharing and communication and drove joint prob- ments toward common goals, particularly during goals. lem solving. This agile, responsive governance the early phase of the partnership. The VG agree- structure was a critical factor in achieving implants ment negotiation relied on a small group of stake- scale-up goals. As a manufacturer representative holders to align on key parameters to ensure explained: confidentiality and minimize potential conflict of An aspect that made this unique and successful was the interest. The broader set of partners were engaged fact that the VG and the Oversight Board brought all the at different levels and at different phases of the ne- required experts around the table with 1 objective: scal- gotiation process to secure commitments and ing up access to this 1 method. People could act quickly achieve alignment. The VG agreements inherently and work together. Without that element, even with created the potential for tensions between those the VG, we would not have been as successful. accountable for the guarantee and those providing An example of how the governance structure the majority of the procurement resources. This supported problem solving was with the forma- tension, which was noted by several interviewees, tion of the Implants Removals Task Force. Access was addressed to some extent through the

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governance mechanisms but remained a chal- The sustained low unit price of the implants lenge throughout the life of the partnership. products was consistently cited by interviewees as the most critical factor to maintaining achieve- ments at the country level. Although the VG end- A key success of ed in 2018, manufacturers have committed Sustainability the IAP was to maintaining the current price through 2023. 6. Continued Efforts and Expanded Resources ’ While this can be considered a key success of the manufacturer s The outlook for sustainability of the gains realized IAP, the price reduction needs to be sustained be- commitment to by the IAP is strong given commitments made by yond this period to ensure long-term implants ac- maintain the partners and the plans to continue and expand cess, and manufacturers will ultimately need an current implant resources. However, price remains a concern effective business case to do so. An equally critical price until 2023. among many key stakeholders. An internal sus- factor to ensuring sustainability is maintaining tainability assessment of the IAP completed in government commitment and political will to 2017 found that support for supply planning, continue efforts to improve access to implants, operations, and market dynamics at the global lev- and the family planning method mix more broad- el should continue to sustain progress, but that ly. Key remaining challenges that were identified these functions would need to be integrated into to maintain and expand progress at the country existing institutions given the formal end of the level are to ensure capacity and access to afford- IAP in 2018. To support such a transition, these able commodities for the private sector and to functions will need to be expanded to include fam- ensure training and human resource considera- ily planning methods generally, not just implants. tions to meet the growing demand for implants Several mechanisms from the IAP have al- removals. ready evolved into institutionalized systems. CSP, as a workstream of the RHSC, continues, and efforts are underway to transition the data visibili- Summary ty tools and processes to support supply coordina- Overall, this evaluation demonstrates that the IAP tion to the Global Family Planning Visibility and was relevant to the needs of the family planning Analytics Network. This platform will capture community and effective at achieving its objec- and use supply chain data from multiple sources tives. However, challenges do remain. Evidence and organizations to provide enhanced visibility also suggests that progress will be sustained over for decision making across multiple family plan- time, with continued global and country efforts. ning products. Discussions are also ongoing Focused monitoring will be necessary to maintain with the United States Agency for International progress, particularly to ensure long-term afford- Development (USAID) regarding the feasibility of ability and availability of the product in the global folding the IAP’s Operations Group into USAID’s market. Method Choice community of practice (formerly LARC community of practice). The Implants DISCUSSION Removal Task Force is also in the process of evolv- The findings above identify key lessons in terms of ing its mandate to include IUDs. how success was achieved at the global and coun- At a country level, multiple factors point to the try level and provide valuable insights to inform likelihood of maintaining efforts initiated under recommendations for global and country stake- the IAP to increase access to implants. Countries holders in the broader family planning field. In have developed and adapted national implants considering how to apply the lessons learned training methods and curricula for health work- from the IAP, it is also important to consider the ers, and in the case of Uganda, included implants context in which the IAP operated and recent training into a standard curriculum for health global health trends that could impact the rele- worker education programs.22 In addition, the vance, effectiveness, and sustainability of similar family planning dashboards that support linking efforts in the future. The VG was a unique solution of trained providers with family planning com- to address a unique problem of unmet demand modities are in use at a national level in several due to the high price of implants. The price solu- FP2020 countries, significantly improving fore- tion was complemented by other investments to casting efforts. Finally, coordination between in- address access barriers and enabled by the broader country implementing partners and with the context in which the IAP operated, including the MOH has improved, which is essential to manage growing momentum in the family planning field. resources and organize programmatic efforts. Emerging trends that will be important to consider

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for future efforts include positioning family plan- Ultimately, efforts to scale up access to implants ning as part of Universal Health Coverage, increas- must be part of a well-balanced contraceptive ing focus on self-care interventions for sexual and method mix, ensuring a rights-based approach to reproductive health, shifting funding toward do- increasing women’s access to family planning. mestic and pooled financing sources, and creating 3. For price reductions to truly increase access a new product pipeline that could result in poten- to commodities, effective partnerships and com- tial product introduction fatigue. plementary investments are needed. Current trends in family planning financing include in- creasing reliance on domestic resources and Recommendations shifts in donor resources toward pooled financing 1. Integrate and align method-specific efforts mechanisms, such as the Global Financing in support of broader family planning goals to Facility.23 These trends will make efforts to reduce achieve sustainable success and drive progress at prices and increase access to low-cost contracep- both the global and country level. IAP efforts to le- tives even more critical. Ultimately, VGs are only verage and integrate with the broader family plan- 1 option to reduce price and increase access to ning global architecture were critical to success family planning commodities that must be consid- both in increasing access to implants and improv- ered carefully in the unique context of that specific ing the broader enabling environment for contra- commodity, along with other options such as ceptives. The integration with the global family pooled procurement mechanisms, direct buy- planning ecosystem took time to evolve from ini- down of price, or direct investment in suppliers.4,9 tial perceptions of the IAP being a method-specific In the case of the IAP, implant manufacturers effort. The partnership made concerted efforts to viewed their engagement in the VG as a success, become more inclusive and align with the overall both in building a partnership that was successful global family planning agenda. At the country lev- in reaching its goals and in providing a great ex- el, interviewees noted that positioning this effort ample of corporate social responsibility efforts. within ongoing family planning and LARC scale- However, a VG should only be employed with up initiatives was critical from the outset, allowing careful considerations for resource requirements partners to leverage existing political will toward and with a clear understanding of the value from increasing access to LARCs. This alignment en- both a business and social perspective. In the case abled the IAP to both achieve its goals and contrib- of implants, the lower price allowed existing ute to the broader family planning goals to reach resources to be stretched further. At the same additional users. This integration is also critical to time, a price reduction alone is unlikely to be suf- sustaining progress after the program ends. ficient to drive significant scale-up. The comple- 2. Support and align method-specific efforts mentary activities to increase access and improve with country family planning policy and imple- the enabling environment at the country level mentation plans led by government, informed by were critical to success for the IAP, but repre- evidence and starting from a rights-based ap- sented a substantial investment of time and proach. Efforts to scale up contraceptive products resources. For example, the price reduction for should be embedded within existing national implants changed the engagement of manufac- efforts, creating country ownership and building turers and shifted much of the responsibility and political will with respective MOHs and local ser- associated resources for training and product in- vice delivery partners. For the IAP, it was essential troduction to donors and governments. that procurers, technical assistance providers, and 4. Engage partners early and with a high de- implementing partners collaborated effectively gree of transparency to ensure alignment around with their government counterparts, engaged in commitments and accountability to common regular meetings and ongoing dialogue, and sup- goals for successful multistakeholder partnerships. ported the development of national policies and Approaches that engage and coordinate partners guidelines. In-country implementers can also use across sectors and stakeholder groups are increas- evidence from successful smaller-scale introduc- ingly relevant to the family planning field and tion efforts to advocate for national policy change. can drive progress through leveraging existing For example, in Nigeria, in-country implementing resources. The collaborative efforts of IAP partners partners were able to build on evidence from suc- allowed each partner to contribute resources, cessful pilot projects to support the national gov- knowledge, and skills in a coordinated approach ernment to develop a task sharing policy allowing and with a dedicated forum for problem solving community health workers to insert implants. that enabled greater impact than if partners had

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contributed the same resources separately. Early Integrating new content within nurse and mid- engagement of all relevant stakeholders is key to wife curricula goes even further to develop and ensure alignment around common goals, resource sustain provider capacity over the long term. requirements, and individual partner commit- 7. Conduct sensitization and awareness raising ments to achieve goals. This engagement is parti- for family planning and the full range of methods cularly critical with approaches that have an as a key component to ensuring women and cou- inherent risk of tension given the multipartner ac- ples can exercise free and informed contraceptive countability toward VGs. Formalized mechanisms method choice. Efforts to increase scale-up and ac- that support transparency, data sharing, and com- cess to any modern contraceptive method must be munications across stakeholders can drive joint grounded in the reality that women and couples problem solving and increase coordination in across the globe lack access to necessary family support of common goals. This recommendation planning information and often face significant aligns with findings in published literature on the barriers in accessing high-quality family planning core components required for collective impact, care.25 Global IAP efforts correctly focused on la- including a common agenda and shared measure- tent demand for implants, and the lower price ment systems, both critical elements for the IAP’s allowed the family planning community to pro- success.24 cure the quantities needed to meet that demand. 5. Increase data visibility across all levels of the However, country partners identified an ongoing supply chain to better match supply with demand need for client, provider, and community sensiti- and improve forecasting abilities to smooth overall zation and awareness activities targeted at the procurement. At both the global and country benefits of family planning use and how to access levels, increasing data visibility was critical to re- all contraceptive methods and not just focused on ducing supply chain disruptions. At the global lev- increasing use of any specific method. These el, this effort included sharing order data between efforts are critical, not only to ensure women individual manufacturers and procurers to better have knowledge of family planning methods, but coordinate orders and meet country needs, while also to enable women to access contraceptives ensuring this data was not shared between manu- within the context of free and informed choice. facturers to maintain confidentiality agreements. Going forward, the Global Family Planning Limitations Visibility and Analytics Network will continue to This evaluation faced limitations that should be play an important role in data visibility efforts. At considered in interpreting the findings. First, the the country level, increasing supply data visibility country stakeholder interviewees were limited to and providing managers with access to these data only 3 countries. The evaluation wanted to cap- combined with training and consumption data ture a variety of perspectives within a given coun- was a successful strategy to improve supply avail- try, but many other countries increased implants ability at service delivery points. However, the uptake during this period. Additionally, schedul- systems-level constraints around national and lo- ing conflicts beyond our control precluded MOH cal commodity distribution systems are significant officials in 2 case example countries from partici- and represented a barrier to achieving the IAP pation in interviews, which could have provided objectives across case example countries. Beyond valuable perspectives to the evaluation. However, data visibility, investments and opportunities to the evaluation team spoke to multiple implement- improve overall supply chain systems should be ing partners and donors in both countries who had considered as a part of any effort to scale new and worked closely with the MOH during the time pe- underutilized family planning products, given the riod of the IAP. Second, the evaluation was con- challenges that were faced for the IAP at the coun- ducted by Global Impact Advisors, who had try level. previously served as the Secretariat for the IAP. 6. Design training programs with scale-up However, the evaluation team was led by 2 indivi- and sustainability in mind. Innovative training duals who had not previously played any role in approaches were critical to the success of the IAP the IAP, thus reducing the likelihood of any bias by reducing associated costs and allowing limited in interpreting evaluation findings. resources to stretch further. Successful training approaches also incorporated ongoing support for providers to maintain skills for both insertions CONCLUSIONS and removals and embedded training capacity The IAP was one of the largest global efforts to re- within facilities to support and mentor new staff. duce the price of and increase access to implants

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by building a public- and private-sector collabora- expanding-long-acting-and-permanent-contraceptive-use-in-sub- tion that focused on systems change in the family saharan-africa-to-meet-fp2020-goals/. Published 2013. Accessed July 16, 2019. planning field. Over 6 years, the IAP supported 3. Duvall S, Thurston S, Weinberger M, Nuccio O, Fuchs-Montgomery tremendous progress in increasing access to N. Scaling up delivery of contraceptive implants in sub-Saharan implants for women in the world’s poorest coun- Africa: operational experiences of Marie Stopes International. Glob tries. As an outcome of this partnership effort, Heal Sci Pract. 2014;2(1):72–92. CrossRef. Medline tools, systems, and capacity were built that can be 4. United Nations Commission on Life-Saving Commodities for Women leveraged to facilitate future introductions of new and Children. Commissioner’s Report September 2012. https:// www.unicef.org/media/files/UN_Commission_Report_ and underutilized contraceptive products. These September_2012_Final.pdf. Published 2012. Accessed July 16, include family planning dashboards that support 2019. alignment of commodities with trained providers, 5. Jacobstein R. Liftoff: The blossoming of contraceptive implant use in innovative and cost-effective training approaches, Africa. Glob Heal Sci Pract. 2018;6(1):17–39. CrossRef. Medline and mechanisms to support coordination and data 6. Bank D. Guaranteed Impact. https://ssir.org/articles/entry/ sharing among procurers, donors, manufacturers guaranteed_impact. Published 2016. Accessed June 24, 2019. and implementing partners. 7. Implants Access Program: Expanding Family Planning Options for Women. FP2020. http://ec2-54-210-230-186.compute-1. To understand the full extent of its impact, the amazonaws.com/wp-content/uploads/2016/03/IAP_two_pager_ IAP must be placed within the overall context of 2016-REV-jan-21.pdf. Published January 2016. Accessed June 24, the market for contraceptives and the various 2019. influencing factors that may have shaped that 8. Bank D. Guaranteed impact. https://ssir.org/articles/entry/ market. However, the relatively short time frame guaranteed_impact. Published 2016. Accessed June 24, 2019. of the IAP makes it difficult to draw conclusions 9. United Nations Population Fund (UNFPA) Procurement Services. Reproductive Health Interchange. Accessed July 26, 2019. https:// about the evolution and long-term sustainability www.unfpaprocurement.org/rhi-home of the market. Thus, future research should en- 10. Akhlaghi L, Heaton A, Chandani Y. Are procured quantities of deavor to understand the complexity of the mar- implants adequate and appropriate? Modeling procurement, ket for implants and other contraceptives, the inventory, and consumption of contraceptive implants during rapid drivers of change over time, and the factors that uptake. Glob Heal Sci Pract. 2019;7(2):240–257. CrossRef. Medline are likely to influence the sustainability of prices 11. Implants Access Program: Expanding family planning options for and supply after current agreements end in 2023. women. FP2020 website. http://www.familyplanning2020.org/ Program designers and implementers across sites/default/files/Our-Work/ppfp/2018%20IAP%202% the family planning field can use the lessons 20pager_VF.pdf. Published November 2018. Accessed June 24, learned from the IAP to improve collaboration, 2019. build new and strengthen existing supply chain 12. Contraceptive Implants Product Brief. https://www.rhsupplies.org/ uploads/tx_rhscpublications/RHSC_implants_br.pdf. Caucus on and service delivery efforts, and support effective New and Underused Reproductive Health Technologies. public-private collaborations to introduce and Reproductive Health Supplies Coalition. Published January 2011. scale up new and underutilized contraceptive Accessed July 24, 2019. methods. 13. Commitment makers. FP2020. http://www.familyplanning2020. org/countries. Published 2018. Accessed July 24, 2019.

Acknowledgments: The authors would like to acknowledge our 14. Contraceptive Implants Product Brief. Reproductive Health Supplies colleagues at Global Impact Advisors: Amy Adelberger, Lila Cruikshank, Coalition. https://www.fhi360.org/sites/default/files/media/ Scott Rosenblum, and Lauren Windmeyer, for their significant documents/rhsc-brief-contraceptive-implants_A4.pdf. Published contributions to this manuscript. We would also like to thank the IAP 2013. Accessed July 24, 2019. evaluation Steering Committee (Gerald Macharia, Elaine Menotti, John 15. Darroch J, Singh S. Estimating Unintended Pregnancies Averted from Skibiak, Martyn Smith, Nina Strøm), Maryjane Lacoste as the project sponsor, and all individuals who participated in the interviews. Couple-Years of Protection (CYP). https://www.guttmacher.org/ sites/default/files/page_files/guttmacher-cyp-memo.pdf. Published 2011. Accessed September 12, 2019. Funding: This evaluation was funded by the Bill & Melinda Gates Foundation. The authors’ views expressed in this publication do not 16. Jhpiego. Providing Contraceptive Implants Learning Resources necessarily reflect the views of the Bill & Melinda Gates Foundation. Package. Baltimore, MD: Jhpiego; 2015. http://reprolineplus.org/ resources/implants-LRP

Competing interests: None declared. 17. World Health Organization (WHO). Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions Through Task Shifting. https://www.who.int/ REFERENCES reproductivehealth/publications/maternal_perinatal_health/ 1. Family Planning’s Return on Investment. FP2020 website. Accessed 978924504843/en/. Published 2012. Accessed June 24, 2019. July 16, 2019. https://www.familyplanning2020.org/sites/ 18. Moses M, Nassimbwa J, Sekimpi C, Kyateeka FN. Exploring the default/files/Data-Hub/ROI/FP2020_ROI_OnePager_FINAL.pdf regulation of task sharing for access to family planning services in 2. Ngo TD, Nuccio O, Reiss K, Pereira SK. Expanding Long-Acting and Uganda. Lupine J Nursing Health Care. 2018;1(3). CrossRef Permanent Contraceptive Use in Sub-Saharan Africa to Meet 19. Riley C, Garfinkel D, Thanel K, et al. Getting to FP2020: Harnessing FP2020 Goals. https://www.mariestopes.org/resources/ the private sector to increase modern contraceptive access and

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choice in Ethiopia, Nigeria, and DRC. PLoS One. 2018;13(2): training for nurses and midwives in Tanzania and Uganda. Glob e0192522. CrossRef. Medline Heal Sci Pract. 2018;6(3):584–593. CrossRef. Medline 20. Federal Republic of Nigeria, National Population Commission; ICF 23. FP2020: Catalyzing collaboration 2017–2018. FP2020. http:// International. Nigeria Demographic and Health Survey 2013. 2017-2018progress.familyplanning2020.org/content/finance# http://dhsprogram.com/pubs/pdf/FR293/FR293.pdf. Published anchor-sub_chapters-370. Published 2018. Accessed July 24, 2014. Accessed July 14, 2019. 2019. 21. Christofield M, Lacoste M. Accessible contraceptive implant removal 24. Kania J, Kramer M. Collective impact. https://ssir.org/articles/ services: an essential element of quality service delivery and scale-up. entry/collective_impact. Published 2011. Accessed July 26, 2019. – Glob Heal Sci Pract. 2016;4(3):366 372. CrossRef. Medline 25. UNFPA Division of Communication and Strategic Partnerships. State 22. Mugore S, Mwanja M, Mmari V, Kalula A. Adaptation of the train- of world population 2019. https://www.unfpa.org/swop-2019. ing resource package to strengthen preservice family planning Published 2019. Accessed July 26, 2019.

Peer Reviewed

Received: November 5, 2019; Accepted: March 10, 2020; First published online: May 28, 2020

Cite this article as: Braun R, Grever A. Scaling up access to implants: a summative evaluation of the Implants Access Program. Glob Health Sci Pract. 2020;8(2):205-219. https://doi.org/10.9745/GHSP-D-19-00383

© Braun and Grever. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-19-00383

Global Health: Science and Practice 2020 | Volume 8 | Number 2 219 ORIGINAL ARTICLE

What Goes In Must Come Out: A Mixed-Method Study of Access to Contraceptive Implant Removal Services in Ghana

Rebecca Callahan,a Elena Lebetkin,a Claire Brennan,b Emmanuel Kuffour,c Angela Boateng,d Samuel Tagoe,e Anne Coolen,e Mario Chen,a Patrick Aboagye,d Aurélie Brunief

Key Findings ABSTRACT Background: Access to quality removal services is a key compo- n Although most contraceptive implant users in nent of informed choice in contraceptive implant use; however, lim- Ghana are able to access removal services, ited data exist on users’ access to removal services. In Ghana, barriers, including cost, provider reluctance to implants are available across the country and are the most com- remove, and difficult removals, exist. monly used contraceptive method among married women. Methods: From October 2017 and January 2018, we conducted n Providers express confidence in removing a phone survey with a stratified random sample of 1,159 women implants, but many are less confident in their who had obtained an implant from a public-sector Ghana Health ability to perform difficult removals. Service clinic in 2 regions and 1,073 women who had an implant inserted through Marie Stopes International Ghana Key Implications (MSIG) mobile outreach in 2 other regions. We also interviewed 50 women just after receiving an implant removal from MSIG. n Family planning programs should review and We conducted follow-up in-depth interviews with 20 implant strengthen potential gaps in removal service acceptors and 15 implant providers across the 4 study regions. provision including access to removals for Results: More than four-fifths of women in both service delivery outreach clients, financial disincentives for contexts knew that their implant could be removed before its la- removal, and provider training and referral beled duration. Nearly half of public sector clients and one-third systems for difficult removals. of outreach clients reported that their provider only told them of removal access at the place of insertion. Among women obtain- n More research is needed to assess the ing their implant in the public and outreach sectors, respectively, prevalence and consequences of difficult implant 32% and 21% reported ever wanting it removed and 61% and removals in different settings. 55% who attempted removal obtained a removal on the first at- tempt. An additional 17% in each context were successful in hav- ing their implant removed within 1 week of the first attempt. Most women obtained removal from the same place they received their insertion (81% public, 70% outreach). Most women reported INTRODUCTION/BACKGROUND their overall removal experience was very or somewhat easy ontraceptive implants are increasingly becoming an (74% public, 68% outreach). Challenges included cost, provider Cintegral part of the contraceptive method mix availability, interactions with providers, and difficult removals. worldwide. Many countries in sub-Saharan Africa, in Conclusions: Access to implant removal is not universal in particular, are rapidly scaling up implant provision. Ghana. Strengthening removal services in both the public and Since the implementation of the Implant Access outreach sectors is needed to ensure comprehensive access. Program in 2013, which reduced the price of these Congo, Ethiopia, and Ghana, implants now make up implants by half, 53 million implants have been pur- one-quarter to one-half of all modern method use.2 1 chased for low-resource countries. In several countries, Millions of implants are being inserted, but the ex- including Burkina Faso, the Democratic Republic of the tent to which providers and programs are prepared to handle the inevitable increase in demand for implant re- moval services is less clear. Ensuring access to quality im- a FHI 360, Durham, NC, USA. plant removal services at term (labeled duration) or at b RTI International, Research Triangle Park, NC, USA. any other time of a woman’s choosing is key for the c Population Council, Ghana. long-term success of contraceptive implant programs d Ghana Health Service, Family Health Division, Accra, Ghana. e Marie Stopes International Ghana, Accra, Ghana. and, even more importantly, compliance with principles f FHI 360, Washington, DC, USA. of voluntarism and informed choice in contraceptive 3 Correspondence to Elena Lebetkin ([email protected]). adoption and use. Past experience with Norplant in the

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United States, as well as in low-income countries, 5 years, Ghana has procured more than 1.3 million demonstrated that lack of access to implant re- implants.8 In 2013, as part of a government effort to moval services or even the perception of insuffi- expand access to contraceptive implants, GHS re- cient access can be detrimental to the reputation vised its policy on implant provision, allowing of the method and raise serious concerns about 4 community health nurses to insert and remove freedom in contraceptive use. Anecdotal infor- contraceptive implants.11 In addition, access to mation from a variety of contexts, as well as some – contraceptive implants has been promoted through survey data,5 7 points to potential weaknesses in service delivery programs related to implant re- the outreach services of private organizations such moval including inadequate medical equipment, as MSIG, which has provided implants in its mobile insufficient numbers of trained providers, exces- outreach services at GHS facilities in Central and sive fees required for removal or provider bias Western regions since 2011. Implants are an afford- against removal before the product’s labeled dura- able long-acting and reversible method in Ghana tion of use. At present, however, systematic data offered to women for 2 Ghana cedis (42 US cents) on the accuracy or prevalence of these potential in the public sector (inclusive of removal) and free barriers are lacking. of charge through MSIG outreach. At the global level, recognition of the need for Our study had 4 objectives: (1) to measure im- focused attention on implant removal resulted in plant acceptors’ knowledge of the possibility of re- the creation of the Implant Removal Task Force moval before labeled duration of use and when 3 in 2015. Although the task force has been instru- and where to obtain removal; (2) to describe rea- mental for identifying research and programming sons for seeking removal; (3) to estimate the pro- gaps, a dearth of data on the state of removal ser- portion of implant acceptors who were able to get vices, especially from users’ perspectives, remains. their implant removed; and (4) to document bar- We designed this study to generate evidence riers to removal. The study was implemented by on the state of access to removal services for wom- FHI 360 in collaboration with the Population We designed this en receiving implants in Ghana and to identify Council of Ghana, MSIG, and GHS. study to generate areas for improvement that could inform pro- evidence on the grams globally. We chose Ghana for this study be- METHODS state of access to cause it is one of the top implant procuring implant removal countries in the world8 and had unique program- Study Design services in Ghana matic data in the form of electronic medical We conducted a mixed-methods study using a ret- and to identify records, which allowed for identification and sam- rospective design to examine the removal desires areas for pling of implant acceptors. To provide a compre- and experiences of women who had received an improvement that hensive picture of the current situation in Ghana, implant, as well as the experiences of family plan- could inform we examined 2 important service delivery con- ning providers. To capture dynamics surrounding programs texts for implants: public sector provision through access to implant removal services in different ser- globally. static facilities and mobile outreach services. Both vice delivery contexts while also ensuring some the Ghana Health Service (GHS) and Marie Stopes geographic and sociocultural diversity, we con- International/Ghana (MSIG), as well as the United ducted the study in 2 regions with public sector States Agency for International Development service delivery through GHS facilities (Ashanti (USAID)/Ghana health team, have identified ac- and Eastern regions) and 2 regions with MSIG cess to implant removal as an important element mobile outreach services (Central and Western of family planning program strengthening. regions). The study was not designed to support The modern contraceptive prevalence rate comparison between the 2 service delivery con- among married users in Ghana has nearly dou- texts, but rather to inform recommendations for bled in the past few years from 18.4% in 2013 to potential strengthening of services on a larger 30.7% in 2017 with implants making up 2.9% and scale to benefit a greater number of women. To 8.4%, respectively, of the modern contraceptive reach large numbers of women and identify those prevalence rate.9,10 In 2013, 15.7% of married who wanted to have their implant removed, we users were using implants9 and by 2017, this had conducted a phone survey with implant acceptors increased to more than 30%,10 making implants and an in-person exit survey with women receiv- the most commonly used method in the country. ing implant removal services from mobile teams Implant use is also common among unmarried (outreach regions only). In addition, we con- women with 17.8% of contraceptive users report- ducted follow-up in-depth interviews (IDIs) with ing implant use in the most recent survey.10 Use a subset of implant acceptors to obtain a more is widespread across the country, and in the last detailed understanding of the circumstances

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affecting women’s ability to obtain removals to de- not readily available in the rsLog, we oversampled termine concrete ways to improve access, and IDIs women from the rsLog, looked for phone informa- with providers to provide detailed insights into tion in their clinic records, and proceeded to call possible constraints on the service delivery side. those with phones. In outreach regions, we More detailed methods and study results are avail- attempted to recruit all women in the electronic able from the programmatic report published client information center database who met study online. eligibility criteria as the target sample size was not FHI 360’s Protection of Human Subjects expected to be met unless all women were Committee, the Ghana Health Service Ethical recruited. Women in both settings were first con- Review Committee, and the Marie Stopes Interna- tacted by phone by GHS facility or MSIG staff and tional Ethical Review Committee approved this asked whether they would be willing to be con- study. Phone survey participants provided oral con- tacted by a researcher associated with the study sent and in-person exit survey and IDI participants (Figure 1). provided written consent. Exit Interview With Women Receiving an Implant Study Populations and Sample Removal Phone Survey With Implant Acceptors For practical reasons related to the longer duration In the public sector, a mobile and web-based of the program and preliminary information on system known as the reproductive services log the volume of clients seeking removal services, (rsLog) electronically captures family planning exit interviews were only implemented in the out- and reproductive health data from clinic registers. reach context. We interviewed a convenience The rsLog has been in use since January 2015 and sample of women aged 18–49 years obtaining re- was operational in 95 GHS facilities in Ashanti and moval services from MSIG mobile teams to obtain Eastern Regions (approximately 30% of the public information from women who had used an im- sector facilities in the 2 regions) at the time the plant for longer periods. Trained research assis- study was conducted. Similarly, MSIG implemen- tants were deployed at mobile outreach sites on ted its electronic client information center data- discrete days and recruited women as they exited. base in 2014 that includes service delivery data Specific outings were selected based on conve- from outreach and static clinic clients. We focused nience according to scheduled activities. MSIG our sample on women included in these electronic providers asked all eligible women whether records. Eligible women for the phone survey in- they would be willing to participate in the survey cluded those who: (1) had an implant inserted be- and study staff interviewed women in a private tween 1 January 2015 and 31 December 2016 at a location after removal. Data collection was con- GHS facility in public regions or between 1 July ducted during outreach outings until an overall 2014 and 31 December 2016 through MSIG target of 50 interviews were complete. The sample mobile teams in outreach regions, (2) were aged size was determined by budget and logistic 18–49 years at the time of implant insertion, and considerations. (3) had phone information available in their records. IDIs with Implant Acceptors Our sampling approach aimed to complete a We conducted IDIs with a subset of women minimum of 384 interviews of women who had (n=20) who participated in the phone survey and ever wanted a removal in each context (public provided permission to be contacted again. IDIs and outreach). We computed our sample size to were conducted in 1 public (Eastern Region) and be able to estimate the proportion of implant 1 outreach region (Central Region) only for prac- acceptors who were able to get their implant re- tical considerations. The participants represented moved at first attempt with 95% confidence and 4 different profiles: (1) women who obtained re- 5% precision. Sample size calculations also as- moval at first attempt, (2) women who obtained sumed a base estimate of 50% as there was no removal on second or subsequent attempt (re- preliminary information about the indicator of ferred to as “delayed success”), (3) women who interest and to be conservative for sample size made at least 1 removal attempt but had not yet purposes. obtained removal by the time of the study, and In public regions, we selected a random sample (4) women who reported wanting removal but of women stratified by health facility from the had not yet tried to access removal services. rsLog. Given that phone access information was Sample size targets were set to achieve a minimum

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FIGURE 1. Study Sample of Women, Aged 18–49 Years Old, Who Had a Contraceptive Implant Inserted in Public and Outreach Regions, Ghana

Abbreviations: CLIC, Client Information Center; IDI, in-depth interview; RA, research assistant; rsLog, Reproductive Services Log. of 4 IDIs per target profile, influenced by a combi- GHS facilities partnering with MSIG in outreach nation of time and budget constraints and general regions (GHS and MSIG providers) (Figure 1). acceptance that 4–5 IDIs are sufficient to identify the most important themes of a study. Recent evi- Data Collection and Analysis dence indicates that 80% saturation can be Phone and Exit Survey reached within 8 IDIs; we aimed for 8 IDIs for the Trained data collectors conducted phone and in- main group of women with delayed removals person exit interviews between October 2017 and (Figure 1).12 January 2018 in either English, Twi, or Fante, according to the participant’s preference. Res- IDIs With Family Planning Providers pondents to the phone survey were compensated We also conducted IDIs with a convenience sam- 5 Ghana cedis (approximately US$1) in mobile ple of family planning providers (n=15) who con- money pushed to their device; and exit interview duct implant insertions and removals at GHS respondents were provided the same amount in facilities in public regions (GHS providers) and at cash at the time of the interview. At the time of

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the interview, data collectors entered data into audiorecorded all interviews and transcribed tablets containing an Open Data Kit survey pro- them into English. The study team developed code- gram. Data were transferred from the tablets to a books, which included both inductive and deductive secure server immediately using a cellular net- codes. Two team members coded the transcripts us- work or wireless connection. Data were then de- ing NVivo 11 (QSR International, Burlington, MA) leted from the tablets to ensure participant and incorporated periodic intercoder reliability confidentiality. Data collection forms were pro- checks of 15% of transcripts to ensure coding consis- grammed with automatic constraints to minimize tency. The team developed detailed thematic mem- human error. Data collector supervisors per- os to identify key dimensions of each code and formed spot quality checks on the data and an synthesize data. Women whoparticipatedinIDIs analyst at FHI 360 in North Carolina conducted were compensated 5 Ghana cedis (approximately additional quality checks. US$1) for their time and reimbursed for travel We analyzed data by study objective separately expenses to the interview site. Providers did not re- for each study context (public and outreach). For ceive compensation for participating in the study as women who attempted removal, we classified re- the interviews occurred at their workplace during moval by timing of attempt: first attempt, within regular work hours. 1 week of first attempt, longer than 1 week after first attempt, and attempted but not yet removed. RESULTS We further divided unsuccessful removal attempts by stated desire to keep or remove the implant in Phone Survey Results the future. Study Population and Participant Characteristics We calculated sampling weights for the public In the public context, 1,159 women participated sector sample as the inverse of the probability of in the survey, representing a 78.3% response rate selection of implant clients for the phone inter- of women who agreed to be contacted by a views. Weights were calculated based on the num- study research assistant. In the outreach context, ber of implant insertions among women of eligible 1,333 women participated in the study with an age during the study eligibility period at each 80.5% response rate (Figure 1). Survey partici- pants were, on average, aged 28.4–29.6 years, facility as per the rsLog and the total number of married or cohabitating, and had 2.3–2.6 children interviews completed per facility. All analyses (Table 1). Most participants had at least some (e.g., percentages, means, standard deviations, primary education, and in the public regions, and ranges) were weighted; however, we present 30.6% had a high school or higher education, unweighted frequencies to clearly indicate the while in the outreach regions one-fifth had a high available sample size. Results are presented de- school or higher education. scriptively except for the indicators associated The majority of women surveyed in the public with seeking removal, for which we provide and outreach contexts had their implants inserted 95% confidence intervals (CIs) for the public re- for less than the labeled duration of use with only gion data. The relative wealth of all implant accep- 4.1% of women in the public context and less than tor study participants was calculated using a subset 1% in the outreach context reporting having their of variables from the USAID Poverty Assessment implant inserted more than 3 years ago (Table 1). 13 Tool, though as all variables from the tool were Most women (89.5% in public and 93.7% in out- not included in the survey, we were unable to cat- reach context) did not know the name of their im- egorize respondents as below or above the poverty plant; however, most knew the number of rods and line in Ghana, as is the intent of the tool. Rather, its duration of protection. Using this information, we we used principal components analysis to create a estimated that 61.9% of women in the public con- score representing a relative measure of wealth text and 86.3% in outreach had Jadelle. Between within the sample. We used STATA version 7.4%–8.3% of respondents did not provide a re- 13 (StataCorp, College Station, TX) for all analyses. sponse combination that described any available im- plant; thus, we could not determine their implant IDIs type (Table 1). Two trained qualitative interviewers conducted the IDIs with women in the language of their Knowledge of When and Where to Obtain a preference (English, Twi, or Fante) and providers Removal in English between November 2017 and July Most women (88.2% [95% CI=85.8, 90.3] in the 2018 using topic guides. The interviewers public context and 84.3% in outreach) were

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TABLE 1. Contraceptive Implant Acceptor Phone Survey Participants’ Demographic Characteristics by Context, Ghana

Publica Outreach (N=1,159) (N=1,073)

Age, years, mean (SD) 29.6 (6.6) 28.4 (6.2) 18–29, % 53.8 63.1 30–39, % 36.8 30.7 40–49, % 9.4 6.2 Marital status Never married, % 21.4 19.5 Married/cohabitating, % 73.0 76.4 Divorced/widowed, % 5.6 4.2 Parity (n=1152) (n=1062) Mean (SD) 2.3 (1.6) 2.6 (1.6) 0, % 10.2 3.9 1–2, % 49.0 50.1 3–4, % 31.5 33.3 5þ, % 9.4 12.7 Highest education (n=1072) None, % 6.7 5.5 Primary, % 11.0 15.5 Middle, % 51.8 58.4 High school, % 21.7 15.9 >High school, % 8.9 4.7 Religion Christian, % 92.3 93.6 Muslim, % 7.4 4.9 Other/none, % 0.3 1.5 Have health insurance, % 64.7 42.6 Wealth quantiles (n=1155) (n=1073) Lowest, % 16.3 23.9 Second, % 18.2 22.1 Middle, % 21.1 20.3 Fourth, % 22.4 18.0 Highest, % 22.0 15.8 Months since implant inserted Mean (SD) 19.5 (10.8) 14.5 (7.4) 0–6, % 4.9 12.6 7–12, % 34.0 46.3 13–18, % 19.4 13.4 19–24, % 18.7 22.4 Continued

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TABLE 1. Continued

Publica Outreach (N=1,159) (N=1,073)

25–36, % 18.9 4.9 >36 months, % 4.1 0.5 Implant typeb Jadelle, % 61.9 86.3 Implanon, % 29.8 6.3 Unknown, % 8.3 7.4

Abbreviations: SD, standard deviation. a Frequencies are unadjusted; percentages and means are adjusted for sampling weights. b Implant type determined by comparing participant responses to number of rods in their implant and the duration of protection. Response combinations that do not describe any available implant are categorized as unknown.

aware that their implant could be removed before respectively, reported experiencing bleeding side its labeled duration. Most of these women said effects. About three-quarters across both contexts that their provider gave them this information: who did not desire removal reported experiencing 88.9% (95% CI=86.0, 91.3) and 88.4% in the bleeding side effects. Regardless of removal desire 2 contexts, respectively. Across contexts, desire and across contexts, the most common bleeding for pregnancy and experience of side effects were side effect was amenorrhea. Similarly, more wom- the most common reasons women reported that en who wanted a removal, versus those who did their providers told them that an early removal not, reported experiencing nonmenstrual-related was possible. Although approximately two-fifths side effects: 59.6% versus 40.3% in the public of women in both settings said that their provider context and 70.0% versus 38.0% in the outreach told them of at least 2 places where they could ac- context. Dizziness and weight change were the cess to removal, nearly half of study participants in most commonly reported nonmenstrual-related the public context and one-third of outreach side effects. respondents reported that their provider told In terms of social influence to remove implants, them that they could have their implant removed 40.5% and 31.8% of women in the public context only at the site where they had it inserted. For out- who wanted and did not want a removal, respec- reach clients, interviewers clarified that the loca- tively, reported being influenced by someone to re- tion of insertion referred to the outreach services move their implant. Most commonly, this was a (Table 2). neighbor/friend followed by a husband/partner. In the outreach sector, more social influence (51.5%) was reported among women who wanted Reasons for Seeking Removal a removal versus women who did not want a remov- Approximately one-third of women in the public al (29.8%) with the most commonly mentioned in- sector and one-fifth in the outreach sector fluence being a neighbor or friend (Table 4). reported ever wanting to have their implant re- moved regardless of whether they attempted re- moval. The main reason reported for wanting a Experience Seeking Removal removal was experience of side effects, including The majority of women in the public sector who menstrual bleeding side effects, and health con- reported ever wanting a removal also sought re- cerns (62.1% in public sector, 72.3% in outreach) moval (91.9% [95% CI=86.7, 95.1]) (data not (Table 3). shown). Of these, 61.1% (95% CI=54.8, 67.1) Table 4 shows women’s reports of side effects obtained a removal at their first attempt and an with use of their implant and influence by others additional 16.5% (95% CI=12.2, 21.9) obtained a to remove their implant. Among participants who removal within 1 week of first attempt. At the time ever wanted their implant removed, 85.2% and of the survey, 8.1% (95% CI=5.1, 13.6) of women 90.0% in the public and outreach sectors, wanting a removal had not yet had their implant

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TABLE 2. Phone Survey Participants’ Reported Knowledge of Contraceptive Implant Removal Services by Context, Ghana

a Public Outreach (N=1,159) (N=1,073)

% 95% CI %

Aware implant can be removed before labeled duration 88.2 85.8, 90.3 84.3 Told by provider at insertion that implant can be removed before labeled duration (n=1020) 88.9 86.0, 91.3 (n=905) 88.4 Reasons provider mentioned that implant can be removed before labeled durationb (n=923) (n=800) Want children 69.3 N/A 62.6 Side effects 60.5 N/A 62.0 Any reason 26.0 N/A 24.9 Partner disapproves 9.9 N/A 9.5 Told at insertion where removal can be obtained Insertion place only 46.5 N/A 33.3 Place other than insertion place 3.2 N/A 15.2 Insertion place and another place 40.5 N/A 38.1 Not told about any place/don’t know 9.8 N/A 13.4 a Frequencies are unadjusted; percentages and means are adjusted for sampling weights. b Multiple responses possible, spontaneous mention. removed despite attempting at least 1 time. Of cost. Of women who made more than 1 attempt to these women, 4.0% (95% CI=2.3, 6.9) decided obtain a removal, the majority returned to the that they still desired to remove the implant, same facility for all attempts (89.2% in public, 2.2% (95% CI=0.5, 9.8) were unsure if they still de- 78.4% in outreach). A minority of women visited sired to remove the implant, and 1.8% (95% CI=0.9, 2 separate facilities (10.8% in public, 18.9% in out- 3.7) decided that they no longer desired to remove reach) and 2.7% of women in the outreach sector the implant (Figure 2). visited 3–5 facilities to obtain a removal (data not In the outreach sector, 57.1% of women who shown). reported ever wanting a removal attempted to have their implant removed (data not shown) and Barriers to Removal just over half of these women (54.6%) obtained Women who attempted to have a removal were removal on their first attempt. An additional asked about potential barriers they faced. In the 16.7% were able to get a removal within a week of public context, approximately one-fifth reported their first attempt. Of the women who wanted a re- keeping their implant because a provider coun- moval but never attempted removal, the top stated seled to continue using. In the outreach context, reasons were changing their mind (37.5%), too ex- provider counseling to continue using and provid- pensive (16.7%), and being too busy (10.4%) (data er unavailability were each reported by 16.7% of not shown). Approximately one-quarter of women attempting a removal. Just over 10.0% in women had not yet received a removal despite both contexts reported that there was a time that attempting at least once at the time of survey the provider would not remove their implant (Figure 2). though the woman wanted a removal. In the out- Most women tried obtaining a removal from reach context, 13.5% said that the provider could the same place they received their implant not palpate their implant and, thus, could not re- (80.5% public, 71.8% outreach) for their first move. Women also reported complications they attempt. As described above, for outreach clients experienced with implant removal. Approxi- “same place” referred to outreach. Reasons for go- mately 40.0%–50.0% experienced temporary ing to a different place for the first removal attempt pain at the time of removal and/or pain that lasted included distance, scheduling inconvenience, and a few days after the removal. In the outreach

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TABLE 3. Phone Survey Participant’s Reported Desire to Remove Contraceptive Implant, by Context, Ghana

Publica Outreach (N=1,159) (N=1,073)

%%

Report wanting removal 31.8 21.5 Main reason for wanting removal/obtaining removal (n=373) (n=231) Other side effects/ health concerns 37.7 49.4 Bleeding side effects 24.4 22.9 Wanted children 18.7 10.4 Partner disapproved 4.9 5.2 Lost partner/partner away/infrequent sex 3.5 2.6 Other 2.7 4.8 Implant expired 2.5 0.0 Afraid of becoming infertile 2.2 1.3 Sexual side effects 1.4 1.3 Became pregnant 1.1 1.3 Too old/ menopause/ infecund 0.7 0.4 Don’t know 0.2 0.4 a Frequencies are unadjusted; percentages and means are adjusted for sampling weights.

context, over one-fifth of women reported having women started using the injectable. Women who continued pain for more than a few days, and did not adopt a new method cited pregnancy de- 5.2% of women mentioned the same in the public sire (37.4% in public, 18.1% in outreach) and context. Overall, most women reported that their side effects (34.8% in public, 36.1% in outreach) entire experience getting their implant removal— as top reasons. Unmet need, defined as not adopt- from the time they decided to get a removal until ing a method of FP after removal for all reasons the time they got a removal—was very or some- other than desiring pregnancy, reporting no sexu- what easy (73.8% in public, 68.4% in outreach) al activity, or infecundity, was 33.3% in public (Table 5). and 53.5% in outreach (Table 7). Most women who received an implant remov- al reported paying for the service (75.0% in public, Exit Survey Results 84.2% in outreach). The average cost women Fifty women completed the exit survey: 34 in reported for removal services was 15.2–24.6 Central Region and 16 in Western Region. Ghana cedis (US$3.20–$5.00) depending on the Average age was 31.0 years, and more than half service delivery context. Women in both the pub- were married (58.0%) and had an average of lic and outreach sectors also reported spending, on 3.3 children. The participants in the exit survey average, 5.2 Ghana cedis (US$1.10) for transpor- were notably less wealthy than phone survey tation to and from the removal procedure location respondents, with 55% falling into the lowest (Table 6). wealth quintile and no participants representing the highest wealth quintile. Most women had Method Uptake and Unmet Need for Family Jadelle (84.0%) and were getting a removal due Planning After Removal to the implant expiring, with two-thirds of women Approximately one-third of women across con- reporting having had their implant at least texts who had their implant removed reported 60 months. All but 1 of the women interviewed adopting a different method of family planning ei- received their implant removal on the first attempt ther at the time of removal or later. Most of these (data not shown) and two-thirds adopted a

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TABLE 4. Phone Survey Participants’ Reported Contraceptive Implant Side Effects and Social Influence by Context and Desire to Remove Implant, Ghana

Publica Outreach (N=1,159) (N=1,073)

Ever Wanted Never Wanted Ever Wanted Never Wanted Removal Removal Removal Removal (n=373) (n=786) (n=231) (n=842) % % % %

Reported experiencing bleeding side effects 85.2 75.6 (n=230) 90.0 (n=840) 77.3 Most commonly mentioned bleeding side effectsb (n=315) (n=597) (n=208) (n=651) Stopped having period 39.3 37.2 46.6 48.9 Bleed more during period 37.6 25.7 19.7 14.8 Bleed less during period 23.8 25.5 22.1 24.3 Period lasts longer 26.0 23.0 26.4 24.3 Period is shorter 13.8 15.4 18.3 18.0 Reported experiencing side effects (other than bleeding) (n=372) 59.6 (n=784) 40.3 (n=230) 70.0 (n=840) 38.0 Most commonly mentioned other side effectsb (n=227) (n=315) (n=161) (n=320) Dizziness 47.1 26.5 50.3 38.4 Weight change 43.2 40.1 40.4 33.4 Headaches 23.8 26.4 15.5 13.1 Abdominal pain 11.1 21.9 14.9 15.9 Reported someone influenced to stop using implant 40.5 31.8 51.5 29.8 Person(s) influenced byb (n=154) (n=237) (n=118) (n=215) Neighbor or friend 54.9 83.5 54.2 76.9 Husband or partner 42.1 14.4 31.4 12.0 Mother 9.7 7.2 14.4 6.8 Other person/unspecified 3.8 9.9 10.2 10.8 a Frequencies are unadjusted, percentages and means are adjusted for sampling weights. b Multiple responses possible, spontaneous mention.

method immediately, with most receiving a new context had wanted a removal but never implant (93.9%) (Table 8). attempted to get a removal. (This situation was not explored in the public context as it was not commonly reported in the quantitative data) Qualitative Results (Table 9). Client Study Population and Participant Characteristics A subset of 20 implant acceptors from the phone Reasons for Wanting Removal survey, evenly divided between the public and Qualitative IDIs revealed that women’s reasons outreach contexts, participated in IDIs. Five had for seeking removal were often multifaceted. received a removal at first attempt, while 10 re- Apart from 2 women who chose to remove their ceived a removal at second or subsequent attempt implants because they wanted to become preg- and 2 participants wanted a removal but had not nant, all women cited more than 1 reason for obtained a removal at the time of the interview de- wanting a removal. Most of the women inter- spite having tried. Three women in the outreach viewed said that bleeding changes, including

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FIGURE 2. Outcomes Among Women Who Attempted to Have Contraceptive Implants Removed in Public and Outreach Regions, Ghana

aPercentages are adjusted for sampling weights.

prolonged bleeding, irregular bleeding, and amen- in their decision to seek a removal. Most of these orrhea, contributed to their decision to seek re- women said their partners wanted them to get a moval. Several women also reported that other removal due to changes in bleeding or other side side effects contributed to their desire for removal. effects that they worried were harming their Changes in weight were frequently mentioned, health. Seven women stated that their partners though no participants stated that weight change “told” or “forced” them to get a removal: was the only reason for removing: ...The last implant he forced me to remove I had not re- As for me, the particular reason I wanted it removed is moved the plaster when I visited him, so he saw it fresh the way my heart was troubling me and the way I felt and since then he was always on my neck to remove it pain in my abdomen, coupled with how I grew lean. I until I got it removed after just 1 month of insertion. grew lean and became very smallish and my veins were Left to me alone, I would have waited another 5 years visible. I grew lean. —Woman, 22 years old, has because I had 3 children then. —Woman, 34 years 1 child old, has 4 children As the quote above demonstrates, women of- In contrast, a few women reported that their ten experienced a variety of side effects that, taken partners either did not want the removal or sup- together, led them to want a removal. Other ported their own decision to remove without commonly reported side effects that influenced re- exerting pressure: moval decisions included headaches and abnor- I wanted to have it removed and inject the 3 months mal heartbeat or heart palpitations, and a few one. And he said, “Ok, that will be fine”. —Woman, women reported dizziness or nausea. Some wom- 22 years old, has no children en reported that the side effects they experienced interfered with their daily lives or made them un- Apart from partners influencing women to get able to work for some period of time: a removal, 4 women reported that their mothers encouraged them to remove their implants. When it [heart pain] was happening, I couldn’t work for a week. I will be at home all week long. —Woman, Removal Experience 42 years old, has 7 children Nearly half of all clients in both contexts reported About half of the women who participated in that an early removal was more expensive than IDIs also described their partner as playing a role removal at labeled duration:

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TABLE 5. Phone Survey Participants’ Responses on Barriers to Contraceptive Implant Removal and Satisfaction With Services Among Women Who Attempted a Removal by Context, Ghana

Publica Outreach (n=339) (n=132) %%

Reason women reported they could not get a removal when they wanted tob Provider counseled to continue using 20.6 16.7 Provider not available 8.6 16.7 Provider would not remove 11.5 10.6 Provider unable to remove despite trying 0.7 4.6 Implant not palpable 4.4 13.5 Problems at removal site on armc (n=314) (n=101) Temporary pain at time of removal 43.6 46.0 Pain that lasted a few days 43.6 54.1 Scarring 35.2 35.1 Infection/swelling 5.1 5.4 Continue pain 5.2 21.6 Other unspecified 0.0 5.4 Ease of removal experience (among women who had a removal) (n=314) (n=101) Very easy 53.0 55.5 Somewhat easy 20.8 12.9 Somewhat difficult 17.4 16.8 Very difficult 8.8 14.9 a Frequencies are unadjusted; percentages and means are adjusted for sampling weights. b Each of these options were asked as a separate yes/no question. c Multiple responses possible, spontaneous mention.

TABLE 6. Phone Survey Participants’ Reported Costs Associated With Contraceptive Implant Removal Services Reported by Respondents Who Removed Implant by Context, Ghana

Publica Outreach (n=307) (n=101)

Reported incurring cost for removal services not associated with transportationb, % 75.0 84.2 Mean cost incurred, US$c (SD) 3.2 (1.8) 5.0 (1.9)d Reported incurring cost for transportation, % 70.6 55.5 Mean cost incurred, US$c (SD) 1.1 (0.7) 1.1 (1.0)

Abbreviation: SD, standard deviation. a Frequencies are unadjusted; percentages and means are adjusted for sampling weights. b Costs includes fees for supplies, provider, and other facility-associated costs. c Respondents reported costs in Ghana cedis. Costs were converted to US$ using the exchange rate at the time of analysis (21 US cents=1.00 Ghana cedi). Means calculated from women who reported incurring costs only. d One respondent reported a cost of US$52.50, which was an extreme outlier. This response was removed from the analysis.

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TABLE 7. Phone Survey Participants’ Reported Contraceptive Method Uptake and Unmet Need After Implant Removal by Context, Ghana

Publica Outreach (n=314) (n=101) %%

Adopted contraceptive method after removal 35.6 28.7 Method used (n=116) (n=29) Injectable 60.2 72.4 Pill 24.8 24.1 Emergency Contraception 11.1 3.5 Intrauterine device 2.4 0.0 Implant 0.7 0.0 Other 0.8 0.0 Reasons for not adopting method (n=193b) (n=72) Want to get pregnant 37.4 18.1 Side effects/health concerns 34.8 36.1 Lost partner/partner away 11.2 6.9 Partner disapproves 3.9 11.1 Inconvenient 1.3 4.2 Other/unspecified 11.4 23.8 Unmet need for family planning after removalc 33.3 53.5

a Frequencies are unadjusted, percentages and means are adjusted for sampling weights. b Five respondents did not provide a response to this question, thus the reduced sample size. c Unmet need is defined as not adopting a method of family planning after removal for all reasons other than desiring pregnancy, reporting no sexual activity, and reporting infecundity.

Yes, he [the provider] explained that the removal reported being told to come back on a different procedure was generally free at due date, but I was day. A few of these women were told that the pro- charged because I was removing it before the due vider who could remove implants was not avail- date. —Woman, 37 years old, has 3 children able on the day they visited or that they should go to the facility where their implant was inserted. About one-quarter of the women, particularly Several of these women who were experiencing in the outreach context, expressed that cost limits bleeding changes reported being given medication women’s access to removal. Some women in the to treat heavy bleeding or were counseled that outreach context explained that it is often perma- their bleeding changes were normal. nent public facility staff who do removals, rather All women who told providers they were plan- than MSIG outreach workers, and that there is a ning to get pregnant or that their husbands/part- cost associated with the removal in this case. ners did not approve of their use of the implant The same facility that I went for the free family planning were successful in obtaining removal on their first services but those people who came to do it for free for attempt: the community were not around but the regular service I pleaded with them to remove it for me because my hus- providers at the clinic were still here and they told us band didn’t want me to do it and so I didn’t inform him on the day of insertion that we can come for removal before I inserted it. He wasn’t in agreement for me to do at a cost of 30 [Ghana cedis] anytime we want to remove it at all. We even had a quarrel at home because of it. —Woman, 34 years old, has 4 children that....I told them that I didn’t inform my husband. Of the 12 women who had visited a provider at And so he is angry because I didn’t inform him. I also least once but still had their implant, most had some side effects that he is spending money on and

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TABLE 8. Characteristics of Contraceptive Implant Acceptor Exit Interview Participants, Ghana

Interviewees (n=50)

Age, years, mean (SD) 31.0 (7.0) Marital status, % Never married 30.0 Married/cohabitating 58.0 Divorced/widowed 12.0 Parity, mean (SD) 3.3 (1.8) (n=47) Highest education, % None 22.0 Primary 36.0 Middle 42.0 Religion, % Christian 92.0 Muslim 6.0 Other/none 2.0 Have health insurance, % 16.0 Wealth quantiles, % (n=49) Lowest 55.1 Second 28.6 Middle 12.2 Fourth 4.1 Highest 0.0 Months since implant inserted, % (n=48) Mean (SD) 51.4 (16.8) 24 12.5 25–36 12.5 48 8.3 60þ 66.6 Implant typea,% Jadelle 84.0 Implanon 4.0 Unknown 12.0 Adopted contraceptive method after removal, % 66.0 Contraceptive method used, % (n=33) Intrauterine device 3.0 Implant 93.9 Female sterilization 3.0 Continued

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TABLE 8. Continued

Interviewees (n=50)

Reasons for not adopting method, % (n=16b) Want to get pregnant 25.0 Side effects/health concerns 12.6 Partner disapproves 31.3 Inconvenient 18.8 Other/unspecified 12.6 Unmet need for family planning after removalc 24.0

a Implant type determined by comparing participant responses to number of rods in their implant and the duration of protection. Response combinations that do not describe any available implant are categorized as unknown. b One respondent did not provide a response to this question, thus the reduced sample size. c Unmet need is defined as not adopting a contraceptive method after removal for all reasons other than desiring pregnancy, reporting no sexual activity, and reporting infecundity.

TABLE 9. Outcome of Either Removal Attempt or Desire to Remove for Contraceptive Implant Acceptor In-depth Interview Participants by Context, Ghana

Public Outreach (n=10) (n=10) No. No.

Successful removal at first attempt 3 2 Removal at second or subsequent attempt 6 4 Removal not yet obtained 1 1 Wanted removal but have not attempted 0 3

so he is always complaining and so they should remove About half of the women who received it for me. I told them I was scared of my sight and urinat- removals, particularly in the public context, ing problems and I was also scared that my husband reported that the removal procedure was easy or will stop taking care of me and leave me and so I am not painful; however, nearly the same number of pleading with them they should remove it for me. I women, but more evenly split between the public wept in front of them. —Woman, 38 years old, has and outreach contexts, reported that removal was 3 children difficult, painful, or took a long time. Four women (2 in each context) experienced broken rods, deep Women also reported obtaining a removal suc- removals, or nonpalpable removals. cessfully when they told their providers about on- going heavy bleeding or other severe side effects persisting despite treatment, hearing complaints Provider Study Population and Participant from family members at the facility that the wom- Characteristics an was denied a removal, and agreeing to begin Fifteen providers, 8 in the public context and 7 in another method of family planning. Many women the outreach context, participated in IDIs. Seven felt that providers only agreed to perform the re- were community health nurses, 4 were midwives, moval reluctantly: and 2 were nurses; 2 providers in the public con- text held other positions. Most providers in the They were trying to convince me not to remove it. But public context had between 1 and 2 years of expe- since I already made up my mind, they agreed to do it rience both inserting and removing implants, and for me. —Woman, 27 years old, has no children most in the outreach context had between 3 and

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5 years of experience. One provider in the public First of all, you try to counsel the client upon what rea- context had no experience with implant removals. son the person gave. But when you come the first day, we Of the providers from the outreach context, wouldn’t do it for you the first day. If it’s bleeding, we 3 were MSIG staff members; the rest were GHS will try the ibuprofen or the microgynon and then if still providers working in facilities where MSIG con- you go and come back and say it didn’t help you, so still ducts outreach (Table 10). you want to remove, then we do it for you. —Disease control officer with 7 years of experience provid- Provider Perspectives ing implants Most providers who participated in IDIs stated that Two-thirds of providers described the impor- they told women during initial counseling that tance of counseling when women came for they could have implants removed before the ex- removal before the labeled duration. Some provi- piration date; of these, many stated they coun- ders stated that potential side effects may not have seled women that they could have their implant been properly explained at insertion, leading removed if they wished to conceive, while others women to blame an implant for unrelated issues. said they told women they could remove the im- Most providers described demand by a woman’s plant at any time and for any reason. husband or partner as an acceptable reason for re- With the implant, what I normally do is, when I insert it moval. About half of the providers felt it was ap- for you, I tell them it’s not because they’ve stated 3 years, propriate to do an early removal if a client wished you should use it for 3 years. If you want to conceive in a to conceive. However, a few in the outreach con- year or 2, you can come for your removal. That is what I text said they decided whether or not a client was normally tell them. —Community health nurse “ready” to have another child before removing the with 1 year of experience providing implants implant. A few providers also stated that they de- cided whether or not a client’s side effects were se- Nearly all providers expressed that early vere enough or enough time had elapsed since removals were appropriate in the case of severe insertion before agreeing to remove: side effects such as excessive bleeding, heart palpi- tations, or high blood pressure, but almost half When asked why [the client wanted a removal], she said they always tried to treat side effects before said, “I don’t experience my menses and because of that removing an implant: my boyfriend has left me and so I want to remove it. But

TABLE 10. Characteristics of Contraceptive Implant Providers by Context, Ghana

Public Outreach (n=8) (n=7) No. No.

Provider cadre Nurse 1 1 Midwife 2 2 Community health nurse 3 4 Other 2 0 Experience with implant insertion 1–2 years 5 1 3–5 years 0 5 6þ years 3 1 Experience with implant removals No experience 1 0 1–2 years 4 3 3–5 years 0 4 6þ years 3 0

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I am not worried because he left me, but I am worried instruments to perform removals, specifically because I don’t experience my menses as a result of the forceps and autoclaves or other sterilization implant.” And I said, “I won’t remove it for you. equipment. Because it’s just 3 months, I can’t take it off for ” — you. Community health nurse with 1 year of DISCUSSION experience providing implants This study represents one of the few systematic Providers reported a range of costs for implant assessments of contraceptive implant users’ access removal services, and a few reported that they to implant removal in a developing country set- charged more for a removal before the implant’s ting.3,14 Encouragingly, we found that a large ma- expiration. Several providers felt that most wom- jority of implant users in both public and outreach en were able to pay the removal fee, though more settings knew when and where to obtain removal said they were, at times, willing to perform and that more than half of users who had removals for less than their normal fee if the wom- attempted removal were able to get their implant an could not pay. removed on first attempt with an additional Most providers, including all 7 from the public 20%–30% on a subsequent attempt. It is impor- context, reported experiences with removal of tant to note that our measure of “success” in acces- broken or bent rods or rod fragments. Many felt sing removal is crude and does not capture that the frequency with which they encountered experiences where women may have received difficult removals was due to poor insertion by counseling that led them to decide to keep their other providers, including implants being inserted implant. Future research should take into account into muscles or the wrong part of the body. Nearly satisfaction with such provider interactions. half of providers said they had done removals that Removal knowledge and access were not uni- were painful for the client, and some providers versal, however, and many women reported hav- noted that these painful removals could discour- ing only been told that they could have their age implant use in communities. More than half implant removed where they had received it. We of the 15 providers reported ever having made a also found that more than half of women who referral to a different facility or seeking assistance had obtained an implant from an MSIG outreach from other facility staff for difficult removals. provider and said they wanted a removal did not Several providers mentioned using or referring actually attempt to have their implant removed. for x-rays, “scans,” or MRIs to detect implants for Some of these women reported that they changed removal. their mind about wanting their implant removed, and others indicated that cost and the need to Provider Needs travel to a facility presented barriers. Although nearly all providers indicated they felt In addition to describing access to removal ser- This study also confident removing implants due to training and vices, this study also provides some insight into provides insight experience, about one-third of providers, particu- why implant users seek removal before expira- into why implant larly in the public context, reported they did not tion. Our survey results indicate that side effects, users seek feel confident with difficult removals. Most provi- including menstrual bleeding changes, were the removal before ders stated they would welcome—or in some cases predominant reason for desiring early removal. expiration. needed—additional training, with an equal num- However, the qualitative findings provided a ber specifically mentioning additional training on more complete picture, showing that the decision counseling and removal: to remove “early” was often multifaceted. Either a combination of different kinds of side effects or With removal, it involves a lot ...Going into the skin, if side effects coupled with social pressure, particu- you don’t take care you might even infect it. And then if larly husband/partner pressure to remove, would the insertion is too deep...you might even be damaging motivate women to seek early removal. Some some veins, which can lead to blood loss or other women reported that their partners were con- things. At least if I’m able to get the training, at least I cerned about the side effects that they were will get the necessary skills that I will be able to do the experiencing, and others described being forced removal without damaging any tissue or any of this to remove their implant by their partner. thing. —Registered community nurse with 2 years Implant users’ experience and reporting of side of experience providing implants effects appears to also influence their removal ex- Apart from training, nearly all providers perience and explain why they do not always ob- expressed a need for additional equipment or tain removal on first attempt. Several women

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described being encouraged by their provider to Limitations keep their implant with counseling and side effect Our study has several limitations. First, although treatment. This provider reassurance is important the rsLog and client information center electronic for allaying health concerns associated with im- databases provided a unique opportunity to iden- plant use and managing unwanted side effects. tify and contact a large sample of implant users, However, some women made subsequent attempts the systems are both relatively new and the data at removal. Our qualitative results suggest that re- they contained were not complete. In addition to moval to become pregnant or because a partner or incomplete or incorrect phone information, in- herent challenges with a phone survey included husband demands removal appears to more likely phones being turned off, running out of battery, to result in removal than complaints of side effects. poor reception, numbers changing frequently, or Several providers said they would perform removal respondents not answering calls. on request and that they believed that removal We were also limited by how long the elec- should be at the sole discretion of the woman using tronic systems had been in place. Most women the implant. Some other providers and users noted recruited from the systems had had their implant that removal often also depended on provider for less than 18 months, so their experiences may judgment. be different from women who have had their im- Although most women who had obtained an plant for a longer amount of time. While the exit implant removal described their experience as interviews provide perspectives from a few longer- easy, our qualitative findings indicate that difficult term users, the limited sample makes drawing removals, including nonpalpable and bent/broken comparisons across groups difficult. rods, occurred with some frequency. We cannot Finally, the eligibility criterion that women estimate prevalence of difficult removals from have phone information available in their record these data, but several women and most providers carries some risk of selection bias and likely may said that they had experienced a difficult removal. have excluded the poorest women. The experi- More research should explore the extent, causes, ences of some women who may have experienced and consequences of difficult removals in this set- challenges accessing removal services may have ting and elsewhere. been missed or underrepresented. Finally, our data indicate that the financial cost Data indicate that of implant removal is uneven and can, in some the financial cost cases, constrain access. Women seeking removal CONCLUSIONS of implant reported paying a range of fees despite the fact This study provides some reassuring data that removal is uneven that GHS has a documented fee for removal of most women who desire to remove their implant and can are able to receive a removal in a timely fashion. 2 Ghana cedis (approximately 40 US cents) and sometimes However, the results also indicate that not all MSIG outreach has no fee. Both women and pro- constrain access. viders described that fees may differ based on the women are able to access removal when and facility, the length of time a woman has had her where they want and room for program improve- implant, or the reasons for the removal. Such un- ment exists both in the public sector and for mo- even charges for removal present a clear challenge bile outreach services. to free and informed choice for contraceptive use. GHS is committed to improving access to qual- Acknowledgments: We would like to thank the study participants for sharing their time and experiences with us. In addition, we would like to ity FP services to all Ghanaians and has prioritized acknowledge the support of FHI 360 colleagues Alissa Bernholc for the utilization of these study results to improve assisting in the preparation of the sampling frame, Sophie Gao and Emily Keyes for verifying study analyses, and Laneta Dorflinger and Theresa implant service provision. USAID Ghana is work- Hoke for their careful review of the manuscript. ing with GHS to identify and implement interven- tions to improve the quality of implant service Funding: This work is made possible by a grant from the Gates delivery and to ensure women have access to re- Foundation and the generous support of the American people through the U.S. Agency for International Development (USAID), provided to FHI moval services for any reason and at no cost. 360 through Cooperative Agreement AID-OAA-A-15-00045. The Research findings have been disseminated through- contents are the responsibility of FHI 360 and do not necessarily reflect the views of the Gates Foundation, USAID, or the United States out Ghana in a series of events culminating in a na- Government. tional steering committee meeting to synthesize recommendations. A technical working group con- Competing interests:: None declared. vened to revise and update the national implant training materials, and a select group of national REFERENCES and regional FP trainers have now been trained on 1. Implants Access Program: Expanding Family Planning Options for the updated materials. Women. FP2020. http://www.familyplanning2020.org/sites/

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default/files/Our-Work/ppfp/2018%20IAP%202%20pager_VF. 9. Performance Monitoring and Accountability 2020. PMA 2013/ pdf. Published November 2018. Accessed May 31, 2019. Ghana. https://www.pmadata.org/sites/default/files/data_ 2. Jacobstein R. Liftoff: The blossoming of contraceptive implant use in product_results/PMA2020-Ghana-R1-FP-brief.pdf. Published July Africa. Glob Health Sci Pract. 2018;6(1):17–39. CrossRef. Medline 7, 2014. Accessed May 18, 2020. 3. Christofield M, Lacoste M. Accessible contraceptive implant removal 10. Performance Monitoring and Accountability 2020. PMA 2020/ services: an essential element of quality service delivery and scale-up. Ghana: September-November 2017 (Round 6). https://www.pma Glob Health Sci Pract. 2016;4(3):366–372. CrossRef. Medline 2020.org/sites/default/files/PMA2020-Ghana-R6-FP-brief.pdf. Published January 10, 2018. Accessed May 18, 2020. 4. Hubacher D, Dorflinger L. Avoiding controversy in international pro- vision of subdermal contraceptive implants. Contraception. 2012;85 11. Ghana Health Service Family Health Division. Family Health Division (5):432–433. CrossRef. Medline 2015 Annual Report. https://www.ghanahealthservice.org/ downloads/2015_FAMILY_HEALTH_DIVISION_ANNUAL_ 5. Performance Monitoring and Accountability 2020. PMA 2017–18/ Burkina Faso: Implant Use and Removal in Burkina Faso. https:// REPORT.pdf. Published 2016. Accessed May 18, 2020. www.pma2020.org/sites/default/files/PMA2020-Burkina-Faso- 12. Namey E, Guest G, McKenna K, Chen M. Evaluating bang for the R5-Implants-memo-EN.pdf. Published August 22, 2018. Accessed buck: a cost-effectiveness comparison between individual interviews May 18, 2020. and focus groups based on thematic saturation levels. Am J – 6. Performance Monitoring and Accountability 2020. PMA 2017/ Evaluation. 2016;37(3):425 440. CrossRef Kenya: Implant Use and Removal in Kenya. https://www.pma2020. 13. United States Agency for International Development. Poverty org/sites/default/files/PMA2020-Kenya-R6-Implants-Brief.pdf. Assessment Tools. Accessed May 31, 2019. https://www. Published May 21, 2018. Accessed May 18, 2020. povertytools.org/index.html 7. Performance Monitoring and Accountability 2020. PMA 2017/ 14. Daly C, Wickstrom J. Contraceptive Hormonal Implant Removal Ethiopia: Implant Use and Removal in Ethiopia. https://www. Services: Experiences from the ExpandFP Project in the Democratic pma2020.org/sites/default/files/ETR5-Implant-Memo-FINAL.pdf. Republic of the Congo, Tanzania, and Uganda. New York: Published September 19, 2017. Accessed May 18, 2020. EngenderHealth; 2016. Accessed May 19, 2020. https://www. 8. United Nations Population Fund. RHInterchange data. Accessed engenderhealth.org/files/pubs/project/expandfp/Expand-FP- May 31, 2019. https://www.unfpaprocurement.org/rhi-home brief_implant_removals_final.pdf

Peer Reviewed

Received: December 19, 2019; Accepted: March 31, 2020

Cite this article as: Callahan R, Lebetkin E, Brennan C, et al. What goes in must come out: a mixed-methods study of access to contraceptive implant removal services in Ghana. Glob Health Sci Pract. 2020;8(2):220-238. https://doi.org/10.9745/GHSP-D-20-00013

© Callahan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https:// doi.org/10.9745/GHSP-D-20-00013

Global Health: Science and Practice 2020 | Volume 8 | Number 2 238 ORIGINAL ARTICLE

Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal

Prajwol Nepal,a* Ryan Schwarz,a,b,c,d* David Citrin,a,e,f,g,h Aradhana Thapa,i Bibhav Acharya,a,j Yubraj Acharya,k Anu Aryal,i Aaron Baum,h Ved Bhandari,i Laxman Bhatt,i Dipak Bhattarai,i Nandini Choudhury,a,h Binod Dangal,i Meghnath Dhimal,l Santosh Kumar Dhungana,i Bikash Gauchan,i,m Scott Halliday,a,e,f,g SP Kalaunee,i,n Lal Bahadur Kunwar,i Duncan Maru,a,h,o,p,q Isha Nirola,a,r Rashmi Paudel,i Anant Raut,a Hari Jung Rayamazi,i Sabitri Sapkota,i Dan Schwarz,a,b,c,s,t Poshan Thapa,u Pratistha Thapa,i Aparna Tiwari,i Roshani Tuitui,v Eric Walter,w,x Sheela Marua,h,o,y

Key Findings Key Implications

n The average per capita annual cost of a pilot n Policy makers should consider further expansion community health worker (CHW) program in rural and improvement of community health systems to Nepal is US$3.05. make progress toward achieving universal health n Personnel costs, the largest cost driver, coverage and the health-related Sustainable contribute 74% of the total implementation costs Development Goals. and are affected by the number of households n Policy makers may benefit from considering covered, population distribution, geographical alternative implementation scenarios that explore terrain, and supervision structure. 3 challenges with CHWs: payment amount, supervision structure, and integration of new cadres into local primary health care systems.

o a Icahn School of Medicine at Mount Sinai, Department of Health Systems Design Possible, New York, NY, USA. and Global Health, New York, NY, USA. b ’ Brigham and Women s Hospital, Department of Medicine, Division of Global p Icahn School of Medicine at Mount Sinai, Department of Internal Medicine, Health Equity, Boston, MA, USA. New York, NY, USA. c Harvard Medical School, Department of Medicine, Boston, MA, USA. q Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, d Massachusetts General Hospital, Department of Medicine, Division of General NY, USA. Internal Medicine, Boston, MA, USA. r Harvard T.H. Chan School of Public Health, Boston, MA, USA. e University of Washington, Department of Global Health, Seattle, WA, USA. s Beth Israel Deaconess Medical Center, Department of Medicine, Boston, MA, f University of Washington, Department of Anthropology, Seattle, WA, USA. USA. g University of Washington, Henry M. Jackson School of International Studies, t Ariadne Labs, Harvard T.H. Chan School of Public Health and Brigham and Seattle, WA, USA. Women’s Hospital, Boston, MA, USA. h Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, u University of New South Wales, School of Public Health and Community New York, NY, USA. Medicine, Sydney, NSW, Australia. i Nyaya Health Nepal, Kathmandu, Nepal. v Nursing and Social Security Division, Dept of Health Services, Kathmandu, j University of California, San Francisco, Department of Psychiatry, San Nepal. Francisco, CA, USA. w University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, k Pennsylvania State University, College of Health and Human Development, USA. Department of Health Policy and Administration, University Park, PA, USA. x University of Pennsylvania, The Wharton School, Healthcare Management l Nepal Health Research Council, Kathmandu, Nepal. Department, Philadelphia, PA, USA. y m University of California, San Francisco, Health Equity Action Leadership Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology Initiative, San Francisco, CA, USA. and Reproductive Science, New York, NY, USA. n Eastern University, College of Leadership and Development, St. Davids, PA, *Prajwol Nepal and Ryan Schwarz are co-first authors. USA. Correspondence to Ryan Schwarz ([email protected]).

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first global guidelines for CHW program design ABSTRACT and implementation,4 offering important guid- Community health workers (CHWs) are essential to prima- ance to policy makers and locally elected officials ry health care systems and are a cost-effective strategy to looking to improve progress toward SDG targets. achieve the Sustainable Development Goals (SDGs). Nepal has made important gains in health out- Nepal is strongly committed to universal health coverage comes, including a two-thirds decline in maternal and the SDGs. In 2017, the Nepal Ministry of Health mortality and halving rates of stunting between and Population partnered with the nongovernmental orga- 1990 and 2015.5 Despite this, similar to many nization Nyaya Health Nepal to pilot a program aligned countries, Nepal is not presently on track to meet with the 2018 World Health Organization guidelines for 6,7 CHWs. The program includes CHWs who: (1) receive reg- its SDG targets by 2030, with maternal mortality ular financial compensation; (2) meet a minimum education at 239 per 100,000 live births, under-5 mortality level; (3) are well supervised; (4) are continuously trained; at 39 per 1000 live births, and 38% of disability as- (5) are integrated into local primary health care systems; sociated with noncommunicable diseases (NCDs) (6) use mobile health tools; (7) have consistent supply occurring before age 40 years. chain; (8) live in the communities they serve; and (9) pro- vide service without point-of-care user fees. The pilot model has previously demonstrated improved institutional birth Community Health Care in Nepal rate, antenatal care completion, and postpartum contracep- For decades, Nepal has been a leader in communi- tion utilization. Here, we performed a retrospective costing ty health care systems. The country has a long his- analysis from July 16, 2017 to July 15, 2018, in a catch- tory of various CHW models, including both full- ment area population of 60,000. The average per capita time and part-time and paid and voluntary cadres, annual cost is US$3.05 (range: US$1.94 to US$4.70 across 24 villages) of which 74% is personnel cost. Service delivery covering a range of programmatic outreach and and administrative costs and per beneficiary costs for all ser- service delivery foci. vices are also described. To address the current discourse In the 1980s, the Ministry of Health introduced among Nepali policy makers at the local and federal levels, full-time, paid village health workers (VHWs), who we also present 3 alternative implementation scenarios that pol- received 6 weeks of primary health care training ’ icy makers may consider. Given the Government of Nepal s and focused mainly on increasing immunization. commitment to increase health care spending (US$51.00 per After the VHW program was well established, com- capita) to 7.0% of the 2030 gross domestic product, paired munity health leaders were added to support the with recent health care systems decentralization leading to ex- panded fiscal space in municipalities, this CHW program pro- VHWs, promote the health messages they were vides a feasible opportunity to make progress toward achieving spreading, and increase community participation universal health coverage and the health-related SDGs. This in improving the nation’shealth.8 Unlike VHWs, costinganalysisoffersinsightsandpracticalconsiderationsfor community health leaders were unpaid volunteers policy makers and locally elected officials for deploying a who received only 1 month of training and did not CHW cadre as a mechanism to achieve the SDG targets. make home visits, but rather coordinated conve- nient places and time for people to meet them else- where in the community.8 INTRODUCTION In 1988, the government initiated the volun- s the global community works to collectively tary, part-time cadre of female community health Arealize our commitment to universal health volunteers (FCHVs) to focus on increasing uptake coverage (UHC) and the Sustainable Develop- of family planning methods along with immuniza- ment Goals (SDGs), robust community health tions. Both of these groups of health care workers ’ care systems will be a critical foundation.1 Com- were part of Nepal s response to the global move- munity health worker (CHW) programs have in- ment toward primary health care that emerged 9 creasingly received attention and focus as a key out of the 1978 Alma Ata Declaration. The FCHV strategy to achieve the SDGs and UHC, with dra- program was developed as a country-level re- matic increases in global investments and scale- sponse to the global focus on primary health care up of national and subnational programs.2 Strong and has grown to more than 50,000 volunteers evidence suggests the cost-effectiveness of CHW nationally. The FCHV program has been a pillar of programs, with economic returns of up to 10:1.3 improved health care outcomes in Nepal, including The World Health Organization (WHO) has re- national priorities of vitamin A distribution, immu- cently endorsed them as a key mechanism to nization, and antenatal and postnatal care.10 In achieve UHC and SDG 3—ensure healthy lives 2010, Nepal was recognized as a leading country and promote well-being for all at all ages—in the in progress toward achieving the Millennium

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Development Goals, and the FCHV program was the new political context is also an excellent foun- acknowledged as a key component in that effort.11 dation for improved municipality-based CHW ser- In the early 1990s, in line with the new vice delivery. National Health Policy of 1991 aimed at bringing health care services closer to rural communities, Improving Community Health Care Models in the government introduced the maternal and child 12 Nepal health worker (MCHW). Also a full-time, paid To meet the gap in SDG targets in Nepal, it has be- position, MCHWs were charged alongside FCHVs come clear that new ideas and investments need to with covering entire village development commit- be made in CHW systems as part of overall health tees, the smallest geo-administrative unit at the care systems strengthening efforts.14,15,18,19 The time, and were affiliated to rural health care facilities WHO guidelines,4 and other recent recommenda- such as primary health care centers and subhealth 2,20 tions for design of effective CHW programs, of- posts. As educational levels and training opportuni- fer helpful framing in these regards, highlighting ties increased over time,13 VHWs and MCHWs were that CHWs should: (1) receive regular financial transitioned to auxiliary nurse-midwives (ANMs) and compensation; (2) meet a minimum education auxiliary health workers (AHWs), respectively, both of level; (3) be well supervised; (4) be continuously which undergo 18 months of pre-service training. In trained; (5) be closely integrated into the local pri- parallel, the FCHV program continued to grow and now includes more than 50,000 volunteers covering mary health care system; (6) use a mobile health communities throughout all of Nepal’s 7 provinces— tool; (7) have consistent supply chain; and (8) live roughly 1 FCHV per every 500–1000 people in the in the communities they serve. country, and their areas of responsibility have broad- In this context, the nongovernmental organiza- ened to include a range of other maternal, neonatal, tion Nyaya Health Nepal developed a collaborative and child health outreach and services.12 effort with the Ministry of Health and Population, Despite Nepal’s significant successes in com- Department of Health Services, Family Welfare munity health, in particular the FCHV program, Division to implement a CHW pilot program21 that there are areas for improvement for community- was closely aligned with WHO guidelines (Table 1), based cadres. These include having more robust which may offer insight for Nepal’sfutureCHW managerial and training structures, establishing programs. This pilot program has had promising ear- minimum educational requirements, expanding ly results, described in detail elsewhere,22,23 includ- to full-time paid employment (FCHVs are part- ing between 2014 and 2016, improving antenatal time volunteers working on average 7.2 hours care (ANC), institutional birth rate, and postpartum per week), and addressing supply chain manage- ment challenges similar to much of the rest of the contraception (Figure 1). Since 2016, monitoring health care system.14–16 Although improvements data collected in the course of program operations are being made to the FCHV program, including has shown a further increase in the institutional in the new FCHV Strategy 2076 that will outline a birth rate in the catchment area to 96% (unpub- requirement for new FCHVs to have a minimum lished data). More recently, in multiple municipali- educational requirement, as well as other efforts ties across the country, locally elected officials are at local levels where FCHVs are advocating for im- planning or have already begun implementing new proved structure, supervision, and payment, these community-based services, including adjustments challenges make it unlikely that the FCHV pro- to the FCHV program as well as introduction of gram in its current state presents a viable pathway new cadres with a range of training and skillsets toward the SDGs. Indeed, in these regards, in- Understanding creasingly over the last decade, policy discussions (e.g., ANMs). Despite growing interest, there is lim- the available and pilot programs have examined leveraging ited consensus or coordination of how such pro- options as policy additional community-based cadres, including grams or new cadres should be implemented. ANMs, to expand community health.17 Although CHW programs may be cost- makers and Nepal recently transitioned to a federal repub- effective strategies for health care systems locally elected lic, including further decentralization of the health strengthening,3,4 there are limited data in Nepal officials consider care system. Newly elected municipal governments regarding the costs or operational details of what more robust are seeking locally appropriate strategies to better a CHW program aligned with WHO guidelines community-based respond to their constituents’ health care priorities. would entail. Understanding what options are service delivery Although this transition and decentralization available as policy makers and locally elected offi- will be critical to process has brought significant challenges, paired cials consider more robust community-based ser- achieving SDG with Nepal’s commitment to UHC and the SDGs, vice delivery will be critical to achieving SDG targets.

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TABLE 1. Pilot CHW Program Design in Relation to WHO Guidelines

WHO Recommended CHW Program Alignment With Program Attributes4 CHW Pilot Program Descriptive Characteristics WHO Recommendations

Selection CHWs:   Have minimum education requirement of 10th level  Locally selected women who live in the community they serve

Training  Includes both preservice and continuous training   Training combines theory and practice based in community

Certification  Formal program certification is currently in process, pending government – approval

Supportive supervision Supervisors conduct:   Regular in-person supervision including observation in community  Dedicated supervision, data-driven feedback, and performance review

Incentives  CHWs are salaried, full-time employees, at a rate competitive to local  market conditions, paired with additional non-financial incentives

Career ladder  Pending further government certification/approval –

CHW: population ratio  Ratio is based upon epidemiology, geography, topography, security, and  workload/expected responsibilities

Data collection/utilization  CHWs collect data via mHealth platform, use in monitoring and review with  supervisors, use in service delivery improvements

Community integration  CHWs mobilize resources and promote health and social needs 

Supply chain  CHWs have reliable and consistent supply of medicines and supplies closely  linked to local primary health centers

Abbreviations: CHW, community health worker; WHO, World Health Organization.

targets. In these regards, policy makers at federal leverage community health care strategies to and local levels are grappling with multiple ques- achieve UHC and SDG targets. tions, including:  Should CHWs be paid and, if so, how much? METHODS  How should effective supervision structures be implemented? Population and Setting  How can a new CHW cadre be integrated with In 2014, Nyaya Health Nepal began CHW program local primary health care systems? development and implementation in Achham dis- trict in Province 7 working with a catchment area Here, we describe costs for a catchment area population of approximately 36,000. In 2017, the population of 60,000 community members in the pilot study was implemented in both Achham and pilot program, including analysis of per-capita Dolakha districts (Province 3) targeting expansion costs, service delivery costs, and administrative to a catchment area population ultimately of more costs. Secondly, to situate these costs in the con- than 250,000 people.21 The subpopulation of the text of current discussions at the municipal level, pilot described in this analysis included the origi- we provide 3 additional implementation scenarios nal program area, Sanfebagar municipality, and for the pilot CHW cadre to reflect local policy the first expansion area, Kamalbazaar municipali- makers’ considerations. This analysis may be in- ty in Achham, which together have a population structive for locally elected officials and future of 60,504 persons.24 A total of 30 CHWs were community health care systems policy in Nepal, employed in the 2 pilot municipalities during the and more broadly, in similar settings globally that time period of July 16, 2017 to July 15, 2018.

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FIGURE 1. Preliminary Health Care Outcomes of Pilot CHW Program in Nepal, Compared to National and Global Targetsa

Nepal Health Sector Strategy target 90% (2020) 70%

60% Sustainable Development Goal target 90% (2030) 90%

43% Nepal average (2016-17) 69% 57%

47% Endline (2016) 90% 93%

19% Baseline (2014-15) 83% 81%

0% 20% 40% 60% 80% 100%

Contraceptive prevalence rate 4 antenatal visits completion rate Institutional birth rate

Abbreviations: CHW, community health worker. a Data published previously22 and reproduced here in parallel to Sustainable Development Goal and Nepal Health Sector Strategy targets.

Achham is historically one of the most impo- maternal and child health services, such as immuni- verished districts with some of the lowest- zation, nutrition, pneumonia, and diarrhea care; performing health indices in the country.5,10 The pre- and postnatal care; and maternal and newborn government-owned Bayalpata Hospital in Achham care, including emergency obstetric services, as well is operated by a public-private partnership between as several village health posts, which provide a smal- the Ministry of Health and Population and Nyaya ler set of basic primary and ANC services. Health Nepal. Through this public-private partner- ship, the hospital is owned by the Ministry of CHW Program Design, Structure, and Service Health and Population and is financed through fede- Delivery ral, provincial, and municipal budgetary allocations, For the current pilot, the initial program protocols ’ supplemented by Nyaya Health Nepal s own financ- were adapted in collaboration with local govern- ing. Nyaya Health Nepal oversees day-to-day man- ment partners and the Ministry of Health and agement and operation of the facility and all health Population, Department of Health Services, Family care services and is accountable to the Ministry for Welfare Division. regular reporting via the local District Health Office. All CHWs in the pilot: (1) receive regular fi- Bayalpata Hospital serves as a referral facility for nancial compensation; (2) meet a minimum edu- comprehensive emergency obstetric and newborn services and noncommunicable disease (NCD) man- cation level requirement of secondary schooling; agement, in addition to providing adult and pediat- (3) are well supervised; (4) receive continuous ric medicine and basic surgical services for training; (5) are closely integrated into the local Sanfebagar. Similarly, the Achham district hospital primary health care system; (6) use a mobile in Mangalsen serves as the referral facility for health tool; (7) have a consistent supply chain; Kamalbazaar and provides a similar range of ser- (8) live in the communities they serve; and vices. Kamalbazaar also has a government primary (9) provide service without point-of-care user health center that provides basic outpatient care; fees. CHWs are full-time, paid employees of

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Nyaya Health Nepal and assigned to individual vil- followed by 2-week training modules each month lages, or “wards,” according to the political desig- over the following 3 months after baseline family nation of the new federal system. CHW are paid a registration is complete. Continuous ongoing train- starting base salary of Nepalese rupees (NPR) ings are conducted at monthly CHW meetings. 19,930 per month. Nyaya Health Nepal’s procure- CHWs are engaged with several subpopula- ment and operations teams provides CHWs with tions within their catchment area: married wom- supplies to use in their daily work, such as mobile en of reproductive age, children aged 2 years and phones, urine pregnancy tests, blood pressure younger, pregnant and postpartum women, and cuff, measuring upper arm circumference tape, adults with chronic diseases. For each of these and other basic supplies. Each CHW is responsible subpopulations, the CHWs maintain a regular for a population of, on average, 2,000 residents. In home visit schedule and conduct counseling, case a few areas, where the population is very spread detection, and referrals. During home visits, CHWs out and the terrain is more challenging, an addi- conduct urine pregnancy testing; trimester-specific tional CHW is employed to cover the ward. All antenatal counseling and referral; postnatal counsel- CHWs have dedicated supervision, with 1 com- ing and referral (with a strong emphasis on contra- munity health nurse (CHN) supervising, training, ception counseling); age-specific child health and and conducting monitoring and evaluation for nutrition counseling; childhood illness screening 5 CHWs. Community health program associates and referral (based on community-based Integrated supervise 2–3 CHNs and are responsible for pro- Management of Neonatal and Childhood Illnesses, gram planning and administration (Figure 2). and NCD counseling and referral (Figure 2).21 CHWs receive 1 month of preservice training, Services delivered are determined based upon local

FIGURE 2. Program Design of Nepal Ministry of Health and Population, Family Welfare Division and Nyaya Health Nepal CHW Pilot Program

Abbreviations: CHPA, community health program associate; CHN, community health nurse; CHW, community health worker.

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and national priorities and morbidity and mortality of these services. The role of FCHVs is not altered burden. In addition to home visits, CHWs facilitate in the study areas. group ANC sessions at local health posts on a bi- CHWs are equipped with Android-based monthly schedule, with 1 of the monthly visits for smartphones utilizing the CommCare platform27 early gestation (4- and 6-month pregnant women) for clinical service documentation and content to and the other for late gestation (8- and 9-month support counseling and referrals. The data from pregnant women). the CHW smartphones are shared with the Nyaya CHWs coordinate with the existing primary Health Nepal hospital facility-based electronic health care system (including local village clinics, health records to aid in providing continuity of primary health care centers, and hospitals) care between community and facility-based ser- through monthly data sharing and following up vices.23 The supply chain is managed through a on referrals made. They also join monthly FCHV digital inventory management system linked to meetings at local village clinics and coordinate Nyaya Health Nepal’s facility-based electronic with FCHVs to ensure that all pregnant women health record system. No user fees are charged for and children are identified and receiving care. services delivered by CHWs. The structure is close- The program does not alter public health services ly aligned with WHO guidelines for the design and 4,23 coordinated and delivered in the study areas implementation of CHW programs (Table 1). through the Government of Nepal with the excep- The pilot study has been described in detail 21 tion of group ANC. The CHWs work very closely previously. In brief, the pilot is a Type II hybrid with government ANMs at village health posts to effectiveness-implementation research study, evaluat- facilitate group ANC sessions. These sessions are ing effectiveness using a pre-post, quasi-experimental intended to replace individual ANC visits, as phys- design with stepped implementation and evaluating ical assessments and medication distribution are implementation using the RE-AIM framework. conducted during the group along with discussion Enrollment began in 2017 and concluded in 2019, and counseling. Sometimes women present out- with the goal to enroll over 250,000 community side of group visits for individual ANC, but group members across both Dolakha and Achham districts. ANC sessions fulfill all basic ANC requirements. The analysis included in this discussion focuses on a Additionally, CHNs provide antenatal ultrasound catchment area population only in Achham district of and prenatal lab services (including hemoglobin, 60,504 persons across 2 municipalities (Table 2): HIV, blood typing, hepatitis B and C, and urine Sanfebagar municipality (population 36,766) and glucose and protein) during these sessions.25,26 Kamalbazaar municipality (population 23,738). The CHNs receive preservice training as well as ongo- pilot is ongoing and future analysis will include data ing training and assessment to assure the quality for the full catchment area.

TABLE 2. Description and Summary Statistics from Catchment Area of CHW Pilot Program, Including Sanfebagar and Kamalbazaar Municipalities

Sanfebagar Kamalbazaar Total

Total population 36,766 23,738 60,504 Direct service beneficiaries 10,816 8,222 19,038 CHW: population ratio 1:1,935 1:2,158 1:2,017 Community health nurses: CHW ratio 1:4.8 1:5.5 1:5 Total costs (USD$) 118,327 66,177 184,504 Number of CHWs 19 11 30 Number of CHNs 4 2 6 Number of CHPAs 2 1 3 Cost per capita (USD$) 3.22 2.79 3.05

Abbreviations: CHN, community health nurse; CHPA, community health program associates; CHW, community health worker.

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Costing Analysis for regional and national administrative staff were We performed a retrospective costing analysis us- not included given these roles are primarily re- ing demographic, programmatic, and financial sponsible for program design and organizational data for the period between July 16, 2017, and strategy, and are not anticipated to be necessary July 15, 2018. All programmatic information — if the program scales beyond the pilot study. including number of households enrolled in the Similarly, initial programmatic development costs CHW program, number of beneficiaries receiving were not included. All remaining direct and indi- care, CHW encounters and service delivery, and rect costs were attributed to either programs or ad- noncare-delivery events, such as trainings and su- ministrative functions based on their relative use pervision field visits, were collected from the (e.g., transportation costs were partly allocated to CommCare platform and staff program calendars. supervisory systems and to the group ANC pro- CHWs use CommCare to collect household visit gram, and mobile phones and associated technol- data, and these data formed the basis for analyzing ogy support was allocated to data reporting). In CHW resource utilization during care delivery.23 summary, the allocated costs represent annual re- All direct costs (personnel, medicines and con- curring costs of operating the CHW program and sumables, and depreciation of equipment) and in- do not include costs relating to initial training and direct costs (transportation, regular supplies, staff program development. benefits, and depreciation of digital tools) were This approach ensured that all direct and indi- obtained from organizational financial records. rect costs were allocated to the intermediate cost The Nepal Health Research Council (#461/2016) centers of the 6 service delivery programs or the and Brigham and Women’s Hospital Institutional 5 administrative functions. To arrive at final costs, Review Board (2017P000709/PHS) approved the all administrative function costs were further allo- study. Verbal informed consent was obtained by cated downward to service delivery programs CHWs for delivery of patient care and for use of a lim- based on the CHW encounters using a step-down 28 ited identifiable dataset for research analysis. costing methodology. The final cost centers are We employed a ‘top-down’ costing methodol- the 6 service delivery programs. ogy based upon methods previously described by We performed an analysis of programmatic — the Joint Learning Network.28 This methodology cost per capita by village the smallest geopolitical — first disaggregates all direct and indirect costs into division for which there are 14 villages in Sanfebagar municipality and 10 villages in ‘intermediate cost centers’ and second into ‘final Kamalbazaar municipality. Analysis of cost by ser- cost centers.’ Intermediate cost centers consisted vice delivery—pregnancy case detection, individ- of 6 care delivery programs: pregnancy case detec- ual ANC, group ANC, postnatal care, under-2 tion; individual ANC; group ANC; postnatal care; care, and NCD care—was performed for both cost childhood illness management for children aged per capita (of the total catchment area) and for 2 years and younger; and NCD management. cost per beneficiary (for persons who received the Intermediate cost centers also included 5 adminis- service). Notably, group ANC and NCD services trative functions: planning and administration; were available to only 56% and 61% of the popu- training; supervision, monitoring and evaluation; lation, respectively, during the measurement peri- data reporting and learning; and, continuous sur- od. Group ANC limitations were due to certain veillance. Final cost centers consisted of only the villages in both municipalities not having yet 6 care delivery programs. implemented services, and NCD services were not implemented in Kamalbazaar due to constraints at To allocate costs to intermediate cost centers, the local primary health care center for NCD we defined a ‘capacity cost rate’ for CHWs, equal management. to the time spent in each service encounter (avail- All costs were measured in NPRs and con- able from the CommCare database) divided by the verted to US dollars using a conversion rate of We performed the number of available minutes during the year. NPR104.4 to US$1, the average exchange rate for costing analysis to Personnel costs of supervisory and administrative the 1-year measurement period.29 Costs in NPRs generate insights staff (community health program associates and are available upon request. Further costing meth- regarding cost of CHNs, as illustrated in Figure 2) were allocated to odology details are included in Supplement 1. the pilot program administrative functions based on resource attri- as policy makers bution gathered from staff program calendars. consider new Staff benefits and expenses, such as uniforms, Alternative CHW Implementation Scenarios community-based food, and telecom network expenses, were allo- We performed the above-described costing anal- strategies. cated using the same methodology. Notably, costs ysis to generate insights regarding cost of the

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pilot program as policy makers consider new policy makers consider the development of similar community-based strategies. However, in our programs throughout the country. ongoing relationships with federal and local pol- Scenarios have not been tested but are pre- icy makers, we recognize locally elected officials sented for the purposes of considering alternative throughout Nepal are pursuing a variety of policy options. As each scenario also impacts cost, community-based implementation strategies in changes are presented in a cumulative manner in the new federal health context. decreasing order of overall cost; the conditions To address policy makers’ current considerations and cost reductions of scenario 1 are included in regarding implementation of new community- scenario 2, and conditions from both scenarios 1 based services, we present 3 alternative scenarios and 2 are included in scenario 3. for potential implement strategies for a CHW cadre similar to the pilot program:  Scenario 1 projects the implementation costs if RESULTS CHW salaries were decreased. As there is no Program Cost similar CHW cadre in Nepal currently, we used We analyzed the cost for pilot implementation for ’ 30 Nepal s Labor Act definition of minimum villages in 2 municipalities (Table 2) across multi- wage to inform an ‘adjusted salary’ for CHWs ple factors: cost per capita, by administrative func- at scale, determined to be US$1,829.36 annual- tion, by service delivery, cost per beneficiary, and ly (NPR190,985, including government bene- by indirect and direct costs. fits and pension). The analysis by village demonstrated an aver-  Scenario 2 projects implementation wherein age cost per capita in the Sanfebagar municipality administrative functions of the program are of US$3.22 and in the Kamalbazaar municipality absorbed into municipal health care unit gover- of US$2.79 (Figure 3). The overall annual cost of the pilot CHW program during the period was nance structures. Specifically, this scenario US$184,504. The population-weighted average includes the functions performed by communi- annual cost per capita across both municipalities ty health program associates (Figure 2), such as was US$3.05. The overall cost function and varia- program planning, budgeting, evaluation, hu- tion between villages are largely driven by CHW man resources, and financial management, to personnel costs that tend to be a step function be taken on by local governance structures, and increase nonlinearly at population intervals. thereby eliminating the community health pro- The analysis of costs by administrative gram associate cadre. function—planning and administrative; training;  Scenario 3 incorporates the CHW program di- monitoring and evaluation, and supervision; rectly into existing primary health care infra- data reporting and learning; and continuous — structure (e.g., primary health centers or surveillance demonstrated that administrative health posts). In this scenario, the functions of functions comprised 42% of overall costs (with service delivery comprising 58%). These costs CHNs (Figure 2) – supervision, training, and were intermediate costs and were ultimately fur- monitoring and evaluation – would be per- ther allocated to the 6 service delivery areas as fi- formed by government health care facility staff nal cost centers. The largest cost drivers in (e.g., ANMs, thereby eliminating the CHN cad- administrative functions were supervision and re). Additionally, as group ANC services in this monitoring and evaluation, which combined pilot are delivered in large part by CHNs, this comprised 18% of overall costs (Figure 4). There service would be subsumed into local health was no significant variation in composition of care facility service delivery or discontinued. intermediate costs between Sanfebagar and Kamalbazaar municipalities. We developed these scenarios in response to Analysis of final cost centers (pregnancy case the authors’ conversations with multiple stake- detection, ANC, group ANC, postnatal care, under- holders at federal and municipal-levels highlight- 2 care, and NCD) are shown in Figure 5.Pregnancy ing 3 broad challenges: amount of payment for case detection was a leading overall cost driver in- CHWs; CHW supervision structure; and integra- cluding a per capita cost of US$0.75, and with the tion of new CHW cadres into local primary health lowest per beneficiary cost of US$5.74. The highest care systems. These scenarios are intended to com- cost of service per beneficiary was group ANC at plement the costing analysis results and offer in- US$27.06. The higher costs of group ANC were due sight into human resources and implementation to larger time allocation of CHNs in supervision, possibilities as locally elected officials and federal lower number of beneficiaries relative to home

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FIGURE 3. Cost Per Capita of the CHW Pilot Program in Nepal, by Village, N=24

Abbreviations: CHW, community health worker.

FIGURE 4. Distribution of Intermediate Cost Centers, Including Service Delivery and Administrative Functions, of Pilot CHW Program in Nepal, by Municipality

Abbreviations: CHW, community health worker.

visits, and lab and diagnostic services provided dur- geopolitical village boundaries as CHWs are hired by ing group sessions. village. Full program costing is included in Analysis of cost by functional type of expendi- Supplement 2. ture (direct costs covering personnel, equipment and consumables, and indirect costs disaggregated into transportation and other) demonstrated direct Costs of Alternative Implementation costs constitute 81% of overall costs, including staff Scenarios costs of 74%, and transportation the second leading The projected additional per capita costs over and cost driver at 11% (Figure 6). In comparing munici- above current public-sector budgetary allocation palities, personnel in Sanfebagar comprise 78% of for the 3 alternative implementation scenarios of costs but only 66% of costs in Kamalbazaar. This is a CHW cadre are shown in Figure 7. In the first likely due to the fact that CHW-to-population ratio scenario, CHWs would receive an ‘adjusted salary’ and CHN-to-CHW ratios were lower in Kamalbazaar of US$1,829.36 annually, as per minimum wage than in Sanfebagar (Table 2) largely due to stipulations in the Nepal Labor Act,30 which would

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FIGURE 5. Costs Per Capita and Per Beneficiary by Service Delivery of CHW Pilot Program in Nepal

Abbreviations: CHW, community health worker; NCD, noncommunicable diseases.

FIGURE 6. Costs by Functional Type of Expenditure in a CHW Pilot Program in Nepal

Abbreviations: CHW, community health worker. decrease overall program costs by 21% from sector staffing would be required to absorb some of US$3.05 to a per capita cost of US$2.39. For scenar- the administrative costs of CHW program over- ios 2 and 3, while additional per capita costs de- sight. These costs would be contingent upon the crease with integration into municipal governance implementation strategy and are not accounted bodies and primary health care facilities, public- for in the per capita cost presented. The second

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FIGURE 7. Potential Advantages and Disadvantages and Additional Per Capita Cost of 3 Alternative CHW Program Implementation Scenarios, US$

Abbreviations: CHW, community health worker, PHC, primary health care.

scenario wherein program administration is by cost due to inclusion of laboratory tests and ultra- municipal health care units would decrease costs sound services provided during sessions and pres- by 30% for an additional per capita cost of US ence of CHNs at all sessions (with corresponding $1.69. The third scenario would integrate CHWs increased transportation costs). Although women into local primary health care facilities, decreasing in areas where group ANC was not offered were costs by 36%, for an additional per capita cost of also encouraged to receive these diagnostic tests, US$1.07. services occurred at higher-level health care facili- While these scenarios have not been tested in ties where available and thus were not included in the current pilot, Figure 7 also describes potential the cost of CHW program delivery. Costs in the advantages and disadvantages for each. Cost per Sanfebagar municipality were higher, on average, capita and per beneficiary for each scenario and than in Kamalbazaar due in large part to a higher further details of costing are included in staffing to population ratio (Table 2). We did not in- Program costs Supplement 2. clude a cost-benefit analysis as a part of this study were an average due to limitations in data availability. US$3.05 per Nepal, like many countries, has a strong high- capita and were DISCUSSION level commitment to UHC and the SDGs. A CHW largely due to We describe the costs of a pilot CHW cadre, aligned cadre, such as the pilot described, offers one po- human resources with WHO’s guidelines for CHW program design, tential path forward for Nepal and other countries. and to provide operational and financial insight to poli- Although it is difficult to compare costs across pro- transportation. cy makers considering new community-based ser- grams or geographies and our current analysis is vices. The costs for the program were, on average, not a cost-effectiveness analysis, the costs of the US$3.05 per capita, with variation per service program described are broadly aligned with, if not delivered (Figure 5). Similar to other community perhaps cheaper than, programmatic costs in oth- health care programs, costs were largely due to hu- er community-based programs.3,31,33–35 Current man resources and transportation (Figure 6).31,32 health care spending in Nepal is US$51 per capita, Pregnancy case detection and NCD services in- or 6.7% of the 2016 gross domestic product cluded some of the higher costs per capita, though (GDP), and Nepal’s SDG targets have 2 important pregnancy case detection had the lowest cost implications for health care delivery. First, to per beneficiary. Pregnancy case detection was the reach the SDG goals, Nepal intends to increase largest program component by beneficiaries count per capita health care spending from US$51 to in both municipalities, whereas NCD services was US$175 by 2030. The majority of this growth will the second largest in the Sanfebagar area. Group come from Nepal’s intended increase in GDP per ANC services comprised the highest per beneficiary capita from US$759 to US$2,500 by 2030, while

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health care contributions will improve only mar- supervision, which should be taken into account We encourage 4,37–39 ginally, from 6.7% to 7.0% of GDP. Second, to ex- as implementation strategies are considered. policy makers to pand financial risk protection for citizens, Nepal Additionally, although scenarios 2 and 3 require consider how intends to reduce the share of out-of-pocket spend- less per capita budgetary allocation over and implementing a ing from 52% of total health care expenditure above the current health care budget, they also re- CHW cadre can be (2016) to 35% by 2030. Accordingly, public-sector quire public-sector staffing adjustments to ensure locally owned with contributions to health care will need to increase by adequate CHW programmatic oversight, and significant 12% annually in real terms, from US$13.60 of these costs have not been accounted for. Thus, community and government-funded per capita health care spend- we encourage policy makers to consider most im- local governance ing (2016) to US$77 per capita by 2030. Further portantly how implementation of a CHW cadre engagement, be details are included in Supplement 3.Asthe can be locally owned with significant community well-integrated Government of Nepal increases the fiscal space and local governance engagement, be well into existing dedicated to health care, it will need to further in- integrated into existing primary health care systems, corporate CHWs as part of overall health care sys- and have the necessary supportive supervision to primary health tems strengthening efforts.36 optimize impact. care systems, and The recently established federal system of gov- Scenario 1 decreases CHW salaries relative to have the ernance, decentralized health care administration, the pilot program. From a human capital develop- necessary and the newly elected municipal governments ment perspective, this reduction is undesirable as supportive throughout Nepal provide an important opportu- higher salaries enable further opportunity and supervision to nity for enhanced community health delivery. empower women CHWs, many of whom may be optimize impact. The costs presented here provide insight into otherwise unemployed and/or less socioeconomi- what is required to deploy a CHW cadre closely cally empowered. However, in the context of the aligned with WHO guidelines. Conversations health care system and current minimum wage regarding implementation of new community- standards, a lower salary may also increase feasi- based cadres are already occurring at the federal bility and avoid potential perceptions of salary in- and municipality levels where newly elected offi- equity. This could improve collaboration and cials are eager to improve health indices for their integration of the cadre into the health care sys- constituencies. Although the costs of CHW service tem. We believe this scenario is more feasible in delivery are a concern to policy makers, with in- the current political climate. creased health care spending, including if Nepal Scenarios 2 and 3 present important opportu- spends the recommended 7.0% of 2030 GDP on nities for further integration of CHWs into local health care required to meet its SDG targets, the primary health care systems, as well as improved allocation required for a cadre as described in ownership by local governance bodies and stake- the pilot may be quite feasible. Having said that, holders. Strong linkages to primary health care there are multiple other concurrent demands systems and community engagement are key ele- on the MOHP budget that would compete for ad- ments to CHW programmatic success and thus are ditional funding were it to materialize. included in the WHO guidelines for CHW program The 3 alternative implementation scenarios design,4 making this an important potential bene- presented provide additional insight for policy fit of both scenarios. Conversely, the lack of dedi- makers and locally elected officials. Further re- cated supervisors in these scenarios poses risks to search is required to draw conclusions regarding implementation of effective supportive supervision impact and cost, but the scenarios reflect ongoing practices, training, monitoring and evaluation, and conversations at both federal and local municipal supply chain management, with scenario 3 posing levels presently. As highlighted in Figure 7, there greater risk in these regards. are advantages and disadvantages that must be In other examples of CHW program imple- accounted for in considering policy approaches to mentation, CHW supervisors who have additional deploy CHW cadres. In these regards, we caution responsibilities (e.g., providing clinical services at policy makers from accounting only for budgetary the local health post) have experienced challenges implications, as overall programmatic effective- providing the supportive supervision that WHO ness may suffer with more limited supervision guidelines recommend, including regular coach- and administrative oversight (e.g., scenarios ing and mentoring of CHWs, direct observation of 2 and 3), thereby potentially negating the invest- CHW service delivery, and review of performance ment and limiting progress toward UHC and data and community feedback.4,20 These chal- health-related SDG targets. Growing evidence lenges may be for multiple contextually specific globally demonstrates the importance of strong reasons. Health care facility staff who are asked to

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supervise CHWs, in addition to conducting their at health posts and primary health care centers.12 routine clinical or administrative responsibilities, Similarly, the potential to further leverage the ex- frequently do not have the availability, training, tensive reach, infrastructure, and effectiveness of or appropriately aligned incentives to optimize the FCHV network with a new CHW cadre is sig- supportive supervision. This situation can mani- nificant. The CHWs in the pilot described here in- fest in supervisors infrequently visiting communi- teract regularly with FCHVs, including attending ties to observe CHW service delivery or having FCHV meetings, health campaigns, and collabo- limited time and capacity to routinely review rating on health promotion activities. As CHWs data, coach, mentor, and provide performance are charged with enumerating and enrolling all feedback. Scenarios 2 or 3 may pose similar risks. members of every household in their respective As discussed previously, over the last 40 years, catchment areas, they have also historically been Nepal’s community health care system has includ- accompanied by FCHVs during household visits. ed multiple community-based cadres, both full- This has been helpful to ensure CHWs do not miss time and part-time, paid and volunteer, including households or family members while conducting VHWs, community health leaders, MCHWs, ANMs, triage and referral care and community-based di- 8,12,18,40,41 AHWs, and FCHVs. Now, with renewed agnosis, treatment, and counseling. Expansion of and increasing enthusiasm to bolster progress to- a full-time, paid community-based cadre could ward the SDGs through community-based cadres, more deeply and effectively engage FCHVs (e.g., including growing recognition of the need to en- around outreach activities, civil registration and hance capacity in the FCHV cadre, paired with the vital statistics, and routine monitoring and evalu- opportunity of increasing fiscal space at the federal ation activities related to government reporting). and provincial levels, there is an important opportu- Additionally, a CHW cadre like the one described nity to offer guidance on how improvements in the in the pilot may further bolster supervision of community health care system can be optimally FCHVs to include an enhanced focus on regular 17 implemented. skill development, problem solving, performance Because the pilot described here was designed review, professional development, and data feed- before the increasingly popular concept of ANM- back loops as part of routine work. or AHW-based community services, it did not in- corporate these cadres specifically into the pilot methodology. Notably, several CHWs employed Limitations in this pilot program were in fact ANMs. However, Our study includes several limitations. First, our this was not an intentional aspect of the pilot pro- analysis regarding CHW time allocation was con- gram protocol, and performance of CHWs who ducted using top-down allocations of costs from had ANM qualifications were not compared to CommCare. Practically, this equates time required CHWs without ANM certification. As such, while for CHWs to complete a form on mobile phones it may ultimately be the case that AHWs and/or using the CommCare application as a proxy for ANMs are well-positioned to carry forward the time spent providing care; however, this proxy work of such a community-based cadre as described has not been validated. During site visits, the use in this pilot, the data included in this manuscript of Commcare tools were observed, and CHWs cannot specifically comment on this question. also provided self-reported average time required Further research detailing the feasibility of the to conduct a specific type of home visit. No notable ANM or AHW cadre leveraged in this particular ca- differences were found between time stamps from pacity should be considered to address these the CommCare tool and reported numbers. questions. Nonetheless, differences here could impact our anal- Finally, it is important to recognize the oppor- ysis. Additionally, some CHW services and functions tunity a ‘dual-cadre’ system provides in which (e.g., postpartum contraception counseling or time paid full-time CHWs work closely with a volun- required for travel) are not accurately captured using teer cadre to optimize community-based service this methodology; therefore, it is difficult to deter- delivery. Dual-cadre systems are exemplified in mine precise costs for these aspects of service delivery. other countries, including Ethiopia’s health ex- However, given that the top-down costing approach tension workers and health development army includes all costs, these limitations should not impact volunteers. These systems have been employed overall per capita cost. More detailed analysis via historically in Nepal as well, with FCHVs working time-driven activity-based costing would be more rig- in collaboration with VHWs and MCHWs, and orous, but with human resource and financial con- now in various capacities with ANMs and AHWs straints, this was not feasible.

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Second, given that this analysis includes only structure of the pilot is not generalizable, and this 2 municipalities, the external validity of our con- may impact feasibility of a similar program in differ- clusions to other areas throughout Nepal are po- ent contexts. Additionally, the catchment area also tentially limited. The full pilot will cover over includes a hospital run by the same public-private 250,000 persons across 2 districts. The analysis partnership that offers access and quality of services presented includes a subset catchment area of not necessarily generalizable to other regions. 60,504 persons in 1 district. Additionally, as noted, Accessible, high-quality, facility-based services are there was incomplete implementation of group a strong determinant of CHW program impact,4 ANC and NCD services during the measurement thus similar results in areas with less access to qual- period, which may have underestimated per capita ity health care facilities may be less feasible. costs accordingly. Future analysis will include the full catchment area when all service delivery is implemented, but such analysis is not expected for CONCLUSION at least 2 more years. Given the delay anticipated, As Nepal looks ahead toward achieving UHC and these data provide some early insights that may SDG targets, more robust primary health systems help inform decision making in the current policy are required. A new CHW cadre, such as assessed context. in this national pilot, represents an important op- Third, our analysis excluded costs for some ad- portunity. The costs described may be instructive ministrative personnel involved in programmatic for policy makers and locally elected officials in design. We do not believe such personnel would Nepal and may also be relevant to countries with be scalable for the program as they are not involved similar health care settings aiming to improve in service delivery, and budgetary allocations are community health care systems on their path to- likely to be constrained if the government chooses ward the SDGs. to scale the program in other geographies. How- Acknowledgments: We wish to express our appreciation to the Nepal ever, the exclusion of such personnel presumes Ministry of Health and Population for their continued efforts to improve limited further ongoing design and iteration which the public-sector health care system in rural Nepal. We wish to give our may cause challenges for the program’s operations. thanks to our technology partner Dimagi. Lastly, we are deeply indebted to the community and hospital staff, including community health workers, Additionally, these personnel do enhance oversight nurses, and program associates, whose commitment to serving our of the program currently and their absence could patients and dedication to improving the quality of health care in rural Nepal continues to inspire us. affect programmatic quality. Notably, such func- tions could also be fulfilled by local governance Funding: This work was supported by the United States Agency for bodies or primary health care facility staff, as de- International Development (USAID) via a Partnerships for Enhanced scribed in scenarios 2 and 3. Engagement in Research award [sponsor grant number AID-OAA-A-11- 00012 and a National Academy of Science subaward letter Finally, the pilot was implemented in the con- 2000007780] and by the Office of the Director, National Institutes of text of a public-private partnership, through which Health under an Early Independence Award [DP5OD019894] to Duncan Maru (the Eunice Kennedy Shriver National Institute of Child Nyaya Health Nepal oversees day-to-day opera- Health & Human Development (NICHD) and the National Institute of tions of the public-sector Bayalpata Hospital; there- Dental & Craniofacial Research (NIDCR) provided support for this award). The funders played no role in research design, data collection, fore, the generalizability of these results for other data analysis, manuscript write-up, or decision to publish. Any opinions, public-sector institutions should be interpreted findings, conclusions, or recommendations expressed in this article are those of the authors alone and do not necessarily reflect the views of the with caution. Future scale of a CHW cadre is more USAID or the National Academy of Science. likely in public-sector or strictly private-sector set- tings, as public-private partnerships remain limited Competing interests: None declared. in Nepal. This may have overestimated costs of early-stage program development as it includes a REFERENCES higher administrative staffing ratio than would be 1. Hone T, Macinko J, Millett C. Revisiting Alma-Ata: what is the role of necessary in future at-scale efforts. Scenarios 1, 2, primary health care in achieving the Sustainable Development – and 3 attempt to account for this discrepancy by Goals? Lancet. 2018;392(10156):1461 1472. CrossRef. Medline adjusting to the expected minimum wage standard 2. Maternal Child Survival Program (MCSP). 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Nepal: 2018 Article IV International Development; Maternal and Child Health Integrated Consultation—Press Release; Staff Report; and Statement by the Program; 2017. Accessed June 4, 2020. https://www.mcsprogram. Executive Director for Nepal. IMF Country Report No. 19/60. IMF; org/wp-content/uploads/2017/01/CHW-CaseStudies-Globes. 2019. Accessed June 4, 2020. https://www.imf.org//media/ pdf Files/Publications/CR/2019/1NPLEA2019001.ashx 14. Panday S, Bissell P, van Teijlingen E, Simkhada P. The contribution of 30. Labour Act, 2074 (2017). Nepal Law Commission. NPL-2017-L- female community health volunteers (FCHVs) to maternity care in 105434. Nepal: a qualitative study. BMC Heath Serv Res. 2017;17(1):623. 31. Vaughan K, Kok MC, Witter S, Dieleman M. Costs and cost- CrossRef. Medline effectiveness of community health workers: evidence from a 15. Bhuvan KC, Khanal S. Female community health volunteers to reduce literature review. Hum Resour Health. 2015;13(1):71. 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33. Nkonki LL, Daviaud E, Jackson D, et al. Costs of promoting Pakistan. Acta Paediatr. 2018;107(Suppl 471):63–71. CrossRef. exclusive breastfeeding at community level in three sites in Medline South Africa. PloS One. 2014;9(1):e79784. CrossRef. 38. Assegaai T, Schneider H. National guidance and district-level prac- Medline tices in the supervision of community health workers in South Africa: 34. Jaffar S, Amuron B, Foster S, et al. Rates of virological failure in a qualitative study. Hum Resour Health. 2019;17(1):25. CrossRef. patients treated in a home-based versus a facility-based HIV-care Medline model in Jinja, southeast Uganda: a cluster-randomised equivalence 39. Kok MC, Vallières F, Tulloch O, et al. Does supportive supervision – trial. Lancet. 2009;374(9707):2080 2089. CrossRef. Medline enhance community health worker motivation? a mixed-methods 35. Chola L, Nkonki L, Kankasa C, et al. Cost of individual peer counsel- study in four African countries. Health Policy Plan. 2018;33(9):988– ling for the promotion of exclusive breastfeeding in Uganda. Cost Eff 998. CrossRef. Medline Resour Alloc. 2011;9(1):11. CrossRef. Medline 40. Glenton C, Scheel IB, Pradhan S, Lewin S, Hodgins S, Shrestha V. 36. Stenberg K, Hanssen O, Edejer TT-T, et al. Financing transformative The female community health volunteer programme in Nepal: health systems towards achievement of the health Sustainable decision makers’ perceptions of volunteerism, payment and other Development Goals: a model for projected resource needs in 67 low- incentives. Soc Sci Med. 2010;70(12):1920–1927. CrossRef. income and middle-income countries. Lancet Glob Health. 2017;5 Medline – (9):e875 e887. CrossRef. Medline 41. Maes KC, Kohrt BA, Closser S. Culture, status and context in com- 37. Aftab W, Rabbani F, Sangrasi K, Perveen S, Zahidie A, Qazi SA. munity health worker pay: pitfalls and opportunities for policy re- Improving community health worker performance through support- search. a commentary on Glenton et al. (2010). Soc Sci Med. ive supervision: a randomised controlled implementation trial in 2010;71(8):1375–1378. CrossRef. Medline

Peer Reviewed

Received: November 10, 2019; Accepted: May 19, 2020

Cite this article as: Nepal P, Schwarz R, Citrin D, et al. Costing analysis of a pilot community health worker program in rural Nepal. Glob Health Sci Pract. 2020;8(2):239-255. https://doi.org/10.9745/GHSP-D-19-00393

© Nepal et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https:// doi.org/10.9745/GHSP-D-19-00393

Global Health: Science and Practice 2020 | Volume 8 | Number 2 255 ORIGINAL ARTICLE Implementing the Clean Clinic Approach Improves Water, Sanitation, and Hygiene Quality in Health Facilities in the Western Highlands of Guatemala

Jason Lopez,a Sergio Tumax Sierra,a Ana María Rodas Cardona,a Stephen Saraa

Key Findings Resumen en español al final del artículo.

n Water, sanitation, and hygiene (WASH) services and infection prevention supplies are suboptimal ABSTRACT in Guatemalan health care facilities that provide Background: Water, sanitation, and hygiene (WASH) services labor and delivery services. are cornerstones to providing safe health care services and im- n The Clean Clinic Approach resulted in significant proving patient satisfaction and care seeking. The Clean Clinic improvements across many WASH and infection Approach (CCA) uses a 10-step process to support health care prevention readiness indicators despite very little facilities (HCFs) in making incremental, effective cleanliness and infection prevention and control (IPC) improvements, without rely- investment. ing on external investments. We piloted the CCA in Guatemala n Success and sustainment of the Clean Clinic and assessed the extent to which it contributed to quality Approach process relies on: improvements in WASH for IPC. Methods: After developing an assessment tool tailored to the * Establishing clear, concise, ward-specific standards; Guatemalan context, we assessed 11 HCFs in 8 technical areas and scored the facilities on 79 criteria with a total of 100 points. * Orienting staff to their responsibilities as they We conducted a baseline assessment (September to October apply to the standards provided; 2018), second assessment (January 2019), and final assessment * Collecting detailed data collection at the ward (February to March 2019). level; and Results: The 11 HCFs improved their average emergency/ general ward scores from 41 points at baseline to 87 points at * Sharing survey results with health care facility end line, based on a 100-point scale. For delivery wards, the staff, local governments, and the public. scores increased from 50 to 91 points and for postnatal wards from 46 to 90 points. Key Implications Conclusions: The CCA process and tools facilitated a systematic way for HCFs to identify, prioritize, make, and measure WASH n To encourage future expansion of WASH in health quality of care improvements. Training facility staff was funda- care facilities, donors and implementing partners mental to improving quality standards, and involving medical should: and administration staff in joint analysis, coordination, and plan- ning sessions was key to integration and teamwork. Further work * Collaborate with national ministries of health to is needed to increase involvement of local government and com- review and update national guidelines for munity members and to further adapt the process and tools. infection prevention and control in hospitals, * Promote the intervention to hospital directors and regional ministry of health directorates, * Partner with health care facility management to BACKGROUND update the assessment tools according to level report by the World Health Organization/United of care and type of service/ward with ANations Children’s Fund Joint Monitoring Pro- consideration for basic level of service, and ramme (JMP) stated that worldwide, 26% of health * Expand the intervention to include more health care facilities (HCFs) lack basic water services and care facilities and share the results publicly. 21% lack basic sanitation.1 Data from 78 low- and middle-income countries (LMICs) showed that half of 129,557 HCFs lacked access to piped water, 33% did not have an improved toilet, and 39% had no soap for a Save the Children, Washington, DC, USA. handwashing. In all, 2% of facilities provided complete 2 Correspondence to Jason Lopez ([email protected]). water, sanitation, and hygiene (WASH) services.

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WASH services are vital for providing safe CLEAN CLINIC APPROACH health services, improving patient satisfaction, The United States Agency for International Deve- and improving care seeking. According to a lopment (USAID) Maternal and Child Survival 1995–2008 review and meta-analysis, health Program (MCSP) developed the Clean Clinic care-associated infections developed in more Approach (CCA) to empower HCF staff and health 3 than 15% of patients in limited-resource settings. systems to implement simple, low-cost, and effec- Furthermore, the lack of proper infection control tive WASH improvements that are proven to help in HCFs, including WASH, is a driver for antimi- protect patients and staff from infection. CCA crobial resistance, along with inadequate sanita- focuses primarily on management, motivation, tion and water services in general.4 In the world’s and accountability as key drivers to maintaining least-developed countries, sepsis is responsible for WASH and infection prevention services. This 13.8% of newborn deaths and pneumonia is re- approach is similar to the Plan-Do-Study-Act sponsible for 6.1% of newborn deaths.5 Neonatal model for quality improvements that has been infections in HCFs occur partly from the lack or successfully used for infection prevention and inadequate delivery of WASH services. Lack of control (IPC) and has been previously modeled 10–12 WASH services are negatively associated with for use in LMICs. The CCA uses 10 steps to patient satisfaction, thus influencing women’s implement incremental WASH and infection pre- choice for birthing at a facility.6 vention improvements to provide quality health In 2016, 5% of HCFs in Latin America had no care services and prevent health care-associated infections (Figure 1).13 Before implementing the water services.1 In Guatemala, 33% of HCFs lack approach in Guatemala, MCSP previously piloted 24-hour-a-day water service and only 25% have the CCA in Haiti.14 a corresponding maintenance program. For sani- The CCA acknowledges that HCFs face multi- tation, 32% of HCFs lack operational services and 7 ple challenges to improving WASH including 62% had no soap available for handwashing. include missing, incomplete, or poorly imple- Infections cause 26.5% of maternal deaths in mented national standards; limited funding; and Guatemalan hospitals compared to 12.5% of lack of knowledge or adherence to IPC protocols 8 deaths in nonhospital facilities. Of newborn by health workers.15 deaths, 16.8% are caused by sepsis and 5.9% by To mitigate these challenges, the CCA ap- 5 pneumonia. Infections also complicate and in- proach encourages collaboration between pro- crease the cost of treating patients. A case control gram implementers and the national ministry of study from a hospital in Guatemala found that the health to develop WASH for IPC evaluation crite- cost of treatment for any given patient with a ria and ratings systems. Then, the CCA implemen- health care-associated infection was 2.5 times ter works directly with HCFs to improve their higher than treatment without.9 rating to meet local standards by developing

FIGURE 1. 10-Step Clean Clinic Approach for WASH Quality Improvements

9. Reward HCF progress 1. Conduct HCF assessment 8. Conduct 10. Refine priorities 2. Establish/refine national inspections, and action plans minimum WASH standards scoring, and and continue for HCFs coaching and improvements 3. Develop program Clean Clinic share results parameters with government 4. Train district and HCF leaders 5. Introduce CCA programs in target HCFs 6. Integrate WASH 7. Implement the actions into annual CCA program action/work plans activities

Abbreviations: CCA, Clean Clinic Approach; HCF, health care facility; WASH, water, sanitation, and hygiene.

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action plans and making incremental WASH delivery care services in the Western Highlands of improvements on their own. Guatemala that were selected by MCSP and the The CCA intervention in Guatemala aimed to MSPAS from MCSP-supported facilities (Table 1 increase the availability of functional WASH infra- and Table 2). structure and basic infection prevention supplies at HCFs through incremental monitoring and Initial Evaluation management and behavioral improvements with- The MSPAS and MCSP developed a monitoring out relying on external investments. Specifically, strategy based on the WHO standards for improv- the intervention aimed to: (1) define a package of ing quality of maternal and newborn care in health quality standards to monitor WASH components facilities while integrating the JMP basic service used in 11 Ministry of Public Health and Social indicators for WASH in HCFs.17,18 MCSP con- Assistance (MSPAS) HCFs with delivery care ser- ducted an initial evaluation in January 2018 of the vices in the Western Highlands of Guatemala, 11 HCFs across 3 wards: emergency/general, labor along with a tool and process for monitoring and and delivery, and postnatal and recovery. This supporting progress; (2) serve as a basis for the de- evaluation provided a snapshot of WASH and IPC velopment of a training curriculum in WASH for services to guide monitoring and improvement hospitals, centers for permanent attention (centros priorities.18 de atención permanente, CAPs), and centers for inte- MCSP and USAID presented the initial evalua- gral attention of maternal and child health (centros tion results to MSPAS leadership (vice ministry for de atención integral materno infantil, CAIMIs) in hospitals and CAPs/CAIMIs) and garnered national Guatemala; and (3) institutionalize the Clean support for implementing a pilot CCA intervention. Clinic quality standards, tools, and process within the MSPAS systems. This case study examines to what extent the CCA Tool Development CCA intervention improved WASH quality stan- Using the results of the initial evaluation, the MSPAS dards for IPC. Central Team; the Board of the Comprehensive Health Care System; the Department of Regulation of the Health and Environment Programs of the METHODS General Board of Health Regulation, Control, and In Guatemala, the MSPAS is responsible for up- Surveillance; and the General Coordinator of holding the national policies for potable water Hospitals, together with 4 MCSP staff members and sanitation, as well as WASH in HCFs as a (2 advisors and 2 specialists; 3 doctors and 1 graduate whole.16 Although national policies on WASH in nurse), formed a working group to develop an assess- HCFs existed, tools for monitoring the WASH sta- ment tool for quality standards and their respective tus of facilities had yet to be developed as of the criteria. start of the intervention. CCA implementation be- The assessment tool evaluates across 8 techni- gan in March 2018 in 11 MSPAS HCFs with cal areas: (1) water; (2) sanitation; (3) hygiene;

TABLE 1. MCSP Facilities Implementing Clean Clinic Approach, Western Highlands, Guatemala, N=11

Level of Care Type of Facility No. Description

Secondary Centers for integral attention of maternal and child health 2  Provide “normal and “uncomplicated” births  Open 24 hours/day  Capacity for minor surgeries including cesarean deliveries and postabortion care Centers for permanent attention 5  Provide “normal and “uncomplicated” births  Open 24 hours/day Tertiary District hospitals 3  Open 24 hours/day  Capacity for major surgeries Regional hospitals 1  Open 24 hours/day  Capacity for major surgeries and specialties

Abbreviations: MCSP, Maternal and Child Survival Program.

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TABLE 2. Clean Clinic Approach Implementation Timeline in Guatemala

Date Activities

2018 January Initial evaluation of health care facilities February Presentation of initial evaluation results to MSPAS and decision to move forward with CCA March Clean Approach implementation begins April Define quality standards, criteria, and weighting thereof May June Familiarize staff with tool in 11 health care facilities July August September Baseline assessment (first measurement) October Identify gaps and define plans for continuous quality improvement November Supervision of improvement plans, coaching, and mentoring December 2019 January Supervision of improvement plans and second measurement February Supervision of improvement plans and third measurement March Certification of establishments according to established categories: silver, gold, and diamond April Closures and delivery of recognition to establishments and staff

(4) sterilization; (5) waste management; (6) envi- (doctors, nurses, sanitation inspectors, rural health ronmental cleaning; (7) administration and docu- technicians, and administrative staff) to provide an mentation; and (8) hot water, wastewater, and overview of the CCA, the assessment tool, and the stormwater. The emergency ward criteria also national guidelines. HCF staff provided feedback on encompassed general facility attributes such as ad- the assessment tools, and some corrections and ministration or wastewater. The tool consists of adaptations were made. Subsequently, MCSP 79 criteria, which vary by ward and are weighted and MSPAS representatives tested the tool in a according to their impact on IPC, totaling a score hospital and a CAP, allowing the team to clarify of 100 points. Figure 2 provides the scoring distri- language and protocols as well as establishing ap- bution for the assessment tool by ward and techni- propriate timing and locations for the application cal area, and Supplement 1 includes the final tool. of the tool.

CCA and Tool Sensitization Health Care Facility Quality Improvements MCSP held a workshop with the MSPAS Central MCSP and the MSPAS Central Team established Clean Clinic Teams Team on using and implementing the newly “Clean Clinic Teams” at each HCF to jointly per- at each facility developed assessment tool that incorporated key form 3 assessments with MCSP. Using the final- together with national guidelines on controlling and preventing ized Guatemala CCA assessment tool, a baseline MCSP conducted nosocomial infections.19 Afterward, MCSP held assessment was conducted across 3 wards in each baseline a workshop with MSPAS regional directorates, facility from September 2018 to October 2018 to assessments to municipal government representatives (responsi- identify existing gaps in WASH for IPC services. identify existing ble for the infrastructure of the 5 CAPs and An additional assessment was conducted in gaps in WASH. 2 CAIMIs), and directors of the 4 hospitals to out- January 2019, and a final certification assessment line the CCA and share the preliminary results of was performed from February 2019 to March 11 HCFs’ initial evaluation. 2019 (Table 2).

Tool Testing Quality Improvement Plans MCSP held a workshop with the MSPAS Central After analyzing the baseline assessment results, Team and the operational staff of the 11 HCFs the CCTs developed quality improvement plans

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FIGURE 2. Guatemala Clean Clinic Assessment Scoring Distribution in Total, by Ward and Technical Areaa

Total Clean Clinic points 15 6 28 12 20 8 9 2 0 Delivery ward 12 3 40 18 20 6 1

0 Postpartum ward 12 9 40 12 20 6 1

Emergency ward (general facility) 22 7 4 5 20 11 28 3

0 102030405060708090100 Percentage Water Sanitation Hygiene Sterilization Waste management Environmental cleaning Administration and documentation Hot water, wastewater, and stormwater aTotal Clean Clinic score is based on the average between wards.

were approximately 4% of the total CCA imple- BOX. WASH for Infection Prevention and Control Training, Coaching, mentation costs.20 and Mentoring Topics

 Water management: Water supply, storage, and quality Assessments and Recognition Facilities scoring above 70 points were given Clean  Solid waste management: Segregation and internal and external sup- Clinic certification and were rated as silver (70%– ply chain – –  80%), gold (81% 90%), and diamond (91% Sanitation management: Cleaning, disinfection, and use of personal 100%). protective equipment by the staff  After the certification assessments, MCSP and Infrastructure management for hygiene: Toilets, showers, and the MSPAS presented a plaque to each HCF during washbasins of users and health providers and standards of care for infection a public ceremony with the category it reached prevention and control and gave a diploma to each CCA team member in each HCF.

according to an IPC prioritization matrix to identify Ethical Considerations and prioritize the problem(s), identify the causes The Save the Children USA ethics review commit- and prioritization of the problem(s), develop/gener- tee reviewed the CCA project plan and deter- ate possible solutions, and test and implement the mined it was exempt from full review. proposed changes. RESULTS Overall, HCFs Overall, HCFs improved their mean CCA assess- improved their ment scores from 45.6% at baseline (September mean CCA Coaching and Mentoring 2018 to October 2018), to 73.1% at second assess- assessment scores MCSP conducted WASH for IPC training, coaching, and mentoring on management of water, solid ment (January 2019), to 89.3% at end line assess- by more than 40%. ment (February 2019 to March 2019). Individual waste, sanitation, and infrastructure for hygiene ward scores improved with general/emergency (Box). wards increasing by 46.2% (from 41.0% to To facilitate the WASH for IPC trainings, MCSP 87.2%), delivery by 40.9% (from 49.7% to secured external funding for the relevant materi- 90.6%), and postpartum by 44.2% (from 45.7% als and supplies (water filters, personal protective to 90.0%). Administration had the most improve- equipment, boots, tools, and red hazardous waste ment from 0.7% to 7.3%. Cleaning improved the bags and labels). These materials and supplies least from 4.5% to 6.5%. Supplement 2 provides

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detailed results for each facility by assessment increased 54%, with the highest improving by number, ward, and sector. 65%. The 2 CAIMIs saw an average improvement Examining the assessment results through the of 37%, and hospitals improved by 36% (Figure JMP standards for WASH in HCFs, no facilities met 3). basic service levels for sanitation or waste man- 18 agement at baseline (Table 3). At end line, all fa- Water cilities had reached basic levels of service for water The water standard uses 9 criteria and contributes and hygiene, and hygiene improved the most. 15 of the 100 Clean Clinic certification points, The following sections describe the results of based on an average across the 3 wards (Figure the clean clinic assessments in total and by the 2). At baseline, 2 of the 11 HCFs had scores of less 8 technical areas. than 20% and 3 had between 35% and 41%. By end line, 7 facilities met all the assessment water Total Clean Clinic Assessment Scores criteria and the rest had total scores between 96% and 98% (Figure 4a). With the exception of 1 hospital and 1 CAIMI, the Water improvements varied by facility and in- CCA facilities had low levels of overall compliance cluded increased water storage capacity, increased at baseline, with 4 CAPs that had scores below availability of water within the facilities, and in- 35% (Figure 3). By the second assessment, com- creased number of water points in priority areas. pliance levels improved as 5 facilities reached sil- MCSP provided all the facilities with a ceramic wa- ver status and 2 reached gold status. By end line, ter filter station or bottled water dispenser in the all 11 facilities achieved Clean Clinic status: 8 facil- 3 evaluated wards. ities achieved gold certification and 3 earned dia- mond status. The closing of gaps in scores between the first Sanitation and third assessments was most pronounced in The sanitation standard contributes 6 of the the 5 CAPs. On average, the CAPs’ compliance 100 points of the Clean Clinic certification over

TABLE 3. JMP Classifications for CCA Facilities at Baseline and End Line Assessment, by Ward and Overall Facility (N=11)

Overall, No. Emergency, No. Delivery, No. Postpartum, No.

JMP Standards Service Category Baseline End line Baseline End line Baseline End line Baseline End line

Water Basic 4 9 3 9 6 10 6 11 Limited 6 2 6 2 3 1 4 0 No Service 1 0 2 0 2 0 1 0 Sanitation Basic 0 5 0 6 1 5 2 8 Limited 8 5 8 4 5 5 5 2 No Service 3 1 3 1 5 1 4 1 Hygiene Basic 2 11 3 11 3 11 2 11 Limited 7 0 6 0 7 0 8 0 No Service 2 0 2 0 1 0 1 0 Waste Management Basic 1 6 1 6 1 6 1 7 Limited 7 4 7 4 7 4 5 4 No Service 3 1 3 1 3 1 5 0 Environmental Cleaning Basic 0 6 0 6 3 6 1 6 Limited 2 1 2 5 1 5 3 5 No Service 9 4 9 0 7 0 7 0

Abbreviations: CCA, Clean Clinic Approach; JMP, World Health Organization/United Nations Children’s Fund Joint Monitoring Programme.

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FIGURE 3. Baseline and End Line Assessment of Overall Compliance Level of Clean Clinic Assessment Criteria Before and After Clean Clinic Approach Intervention, by Facility (N=11)

First Measurement Third Measurement

Hospital 4 70% 98%

Hospital 3 51% 87%

Hospital 2 52% 91%

Hospital 1 46% 86%

CAP 5 50% 89%

CAP 4 32% 87% Facilities CAP 3 25% 90%

CAP 2 31% 90%

CAP 1 31% 81%

CAIMI 2 49% 97%

CAIMI 1 63% 89%

0% 20% 40% 60% 80% 100% Percentage

During the baseline assessment of health care facilities, it was common to find shuttered but functional latrines (left door), resulting in a reduced number of sanitation facilities and gender-segregated bathrooms. Photo Credit: © 2018 Jason Lopez/MCSP

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FIGURE 4. Baseline and End Line Assessment of Facility Compliance Level in Water, Sanitation, Hygiene, and Equipment Sterilization Before and After Clean Clinic Approach Intervention, by Facility (N=11)

A. Water B. Sanitation

Baseline End line

Hospital 4 100% Baseline End line

Hospital 3 72% 100% Hospital 4 58% 100%

Hospital 2 72% 100% Hospital 3 47% 89%

Hospital 1 70% 98% Hospital 2 63% 100%

Hospital 1 84% 100% CAP 5 93%100% CAP 5 47% 79%

Facilities CAP 4 35% 98% CAP 4 26% 89% CAP 3 17% 96% Failities CAP 3 32% 95% 0% CAP 2 41% 98% CAP 2 79%

CAP 1 39% 100% CAP 1 21% 37%

CAIMI 2 11% 100% CAIMI 2 95%100%

CAIMI 1 98% 100% CAIMI 1 68% 89%

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% Percentage Percentage C. Hygiene D. Equipment sterilization

Baseline End line Baseline End line

Hospital 4 75% 100% Hospital 4 100%

Hospital 3 26% 80% Hospital 3 100%

Hospital 2 54% 79% Hospital 2 89% 100% Hospital 1 34% 80% Hospital 1 100% CAP 5 23% 83% CAP 5 74% 100% CAP 4 29% 97%

Facilities CAP 4 71% 94% CAP 3 7% 79% Facilities CAP 3 83% 100% CAP 2 29% 81% CAP 2 66% 100% CAP 1 21% 56%

CAIMI 2 52% 100% CAP 1 74% 94%

CAIMI 1 79% 98% CAIMI 2 89% 100%

0% 20% 40% 60% 80% 100% CAIMI 1 83% 100% Percentage 0% 20% 40% 60% 80% 100% Percentage

5 criteria. At end line, 4 HCFs met all 5 sanitation certification. At baseline, 7 of the 11 establish- criteria, and 4 HCFs had a level of compliance be- ments had critically low compliance levels (below tween 89% and 95% (Figure 4b). CAPs had the 34%). At end line, 1 hospital and 1 CAIMI com- most delays in compliance. One CAP received a fi- plied with all criteria, and 1 CAP and 1 CAIMI nal score of 37% because its emergency room scored above 95%. Six facilities reached compli- restrooms were not separated or signaled by gen- ance levels between 79% and 83% (Figure 4c). der, lacked accessibility for those with mobility The remaining hygiene gaps included the lack issues, and were not clean. of showers with running water and lack of dispos- Improvements to sanitation quality included able towels for drying in delivery rooms and ma- rehabilitation of broken or shuttered sanitation fa- ternal recovery wards. In the delivery rooms, cilities and adding in limited mobility access. All of showers did not provide privacy or facilitate peo- the HCFs improved their restroom signage, clean- ple with limited mobility and their size did not liness, privacy, and gender separation, as well as allow the option of having a companion if the placement of red bags for biological waste in necessary. each restroom. In all of the facilities, handwashing stations were rehabilitated and availability of water, soap, Hygiene and drying towels improved. Eight establishments The hygiene standard has 13 criteria and contri- closed gaps by fixing broken showers. In 1 CAP, butes 28 of the 100 points of the Clean Clinic conditions for handling and cleaning of bedding

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Nonverbal reliant signage and red biomedical waste bags were added to the maternal recovery ward in a hos- pital as a result of the Clean Clinic Approach intervention. Photo credit: © 2018 Jason Lopez/MCSP

improved in the 3 wards. Additionally, 3 facilities assessment wards. MCSP also supported facilities improved their separation of the beds. with training cleaning staff on the correct use of personal protective equipment including lenses, Sterilization masks, gloves, coveralls, and boots. The sterilization standard has 7 criteria and contri- Additionally, facilities identified temporary butes 12 of the 100 points for Clean Clinic certifi- waste collection centers and began monitoring cation. HCFs had a compliance level above 60% in the correct separation of waste. In the 2 CAPs, all services at first assessment. At end line, 9 facili- nursing and custodial staff received direct training ties met all of the criteria and 2 achieved a score of on the correct separation of waste according to the 94% (Figure 4d). standards. Overall, HCFs improved the provision and use of sterile equipment (masks, scissors, clamps, and Environmental Cleaning gowns). The environmental cleaning standard consists of 9 criteria and provides 8 of the 100 certifica- Waste Management tion points. At baseline, 7 HCFs met between The waste management standard has 11 criteria 65% and 74% of the environmental cleaning and contributes 20 of the 100 certification points. criteria. Two hospitals had scores of 41% to At baseline, 7 facilities met less than 35% of the 46%, and 2 CAPs had a compliance level of at or criteria; CAPs and hospitals had the lowest scores. below 35% (Figure 5b). At end line, 2 facilities At end line, 6 establishments met all waste criteria met all 9 cleaning criteria and 6 reached compli- and the remainder reported levels of compliance ance levels between 87% and 96%. above 80% (Figure 5a). Seven facilities developed and published The activities for improving waste manage- cleaning control schedules and improved their ment included the correct separation of waste compliance for scheduled reporting. Five facilities into red, black, and white bags and the addition trained the custodial and nursing staff in the prop- of rigid containers for holding sharps in the er preparation and use of chlorine dilutions. Two

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FIGURE 5. Baseline and End Line Assessment of Facility Compliance Level in Waste Management; Environmental Cleaning; Administration and Documentation; and Hot Water, Wastewater, and Stormwater Before and After Clean Clinic Approach Intervention, by Facility (N=11)

A. Waste management B. Environmental cleaning

Baseline End line Baseline End line

Hospital 4 53% 100% Hospital 4 70% 100%

Hospital 3 57% 80% Hospital 3 74% 87%

Hospital 2 22% 92% Hospital 2 74% 87%

Hospital 1 22% 95% Hospital 1 46% 87%

CAP 5 73% 100% CAP 5 33% 100%

CAP 4 28% 80% CAP 4 35% 74% Facilities Facilities CAP 3 18% 98% CAP 3 65% 87%

CAP 2 23% 100% CAP 2 41% 74%

CAP 1 18% 100% CAP 1 74% 87%

CAIMI 2 57% 100% CAIMI 2 70% 96%

CAIMI 1 32% 100% CAIMI 1 67% 70%

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% Percentage Percentage C. Administration and documentation D. Hot water, wastewater, and stormwater

Baseline End line Baseline End line

0% Hospital 4 29% 93% Hospital 4 0% Hospital 3 14% 86% Hospital 3 4% 52% Hospital 2 7% 100% Hospital 2 54% Hospital 1 7% 50% Hospital 1 4% 14% 44% CAP 5 7% 64% CAP 5 4% CAP 4 57% Facilies 0% CAP 4 4% 62%

CAP 3 100% Facilities 0% CAP 3 14% CAP 2 14% 100% 0% 0% CAP 2 22% CAP 1 100% 0% 0% CAP 1 24% CAIMI 2 79% 0% 0% CAIMI 2 58% CAIMI 1 29% 0% CAIMI 1 20% 38% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% Percentage Percentage

CAPs and 1 CAIMI developed a manual on tasks handwashing stations, waste disposal areas, and and responsibilities for cleaning staff. Two CAPs water sources and training custodial staff on worked with the district and municipalities to im- cleaning and waste management procedures. prove the availability of chlorine and detergent. The facilities developed facility WASH imp- One CAIMI improved storage, disposal of cleaning rovement plans; a drinking water management equipment such as mops, brooms, cleaners, deter- protocol; a risk management plan for sanitation gent, and availability of chlorine. services; standard operating procedures for clean- ing beds, cots, floors, sinks, and toilets; and a hospi- Administration and Documentation tal solid waste management protocol. These plans The administration and documentation standards and documents were shared among the participat- consist of 14 criteria and contributes 9 of the ing HCFs during a knowledge-sharing workshop. 100 points for certification. This standard had the lowest baseline scores with 10 of 11 facilities scor- Hot Water, Wastewater, and Stormwater ing 14% or lower. At end line, 4 facilities met all of The hot water, wastewater, and stormwater the criteria and another 4 required improvement standards consist of 11 criteria and provide 2 of in their documentation processes (Figure 5c). the 100 points for certification. This standard pre- Activities for score improvement included sented the most challenges for closing gaps. At end placing posters and stickers with key messages on line, only 1 CAP obtained scored 62%; 2 hospitals

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and 1 CAIMI scored higher than 50%. The stated that they were motivated to follow existing, remaining HCF’s compliance levels were less than but forgotten, IPC procedures and standards. 40%, and 1 hospital did not meet the criteria The 3 assessments were conducted at planned (Figure 5d). times. Based on the implementation team’s expe- Improvements included installation, rehabili- rience, assessments should be conducted at inter- tation, and maintenance of pipes and hot water in vals of 2 months or more, allowing time for a the showers. Personnel were also trained in the thorough analysis of the findings and planning proper use of PPE for wastewater management, for continuous quality improvement based on the and compliance with tetanus vaccination schemes resources available and the time needed for exe- were verified and managed by the staff. cution. The improvements were subject to weekly facility-level monitoring and follow-up to verify DISCUSSION progress and meet the monitoring and manage- ment needs with those responsible for each The Guatemala CCA intervention demonstrated activity. that the intervention could be implemented in a Clean Clinic teams were encouraged to seek short period of time with limited resources to solutions with the resources available at the facili- achieve quality improvements in WASH services. ty as well as by reaching out to local stakeholders At the end of the intervention, all facilities had im- for support. Implementation and opportunity proved their levels of WASH services by both na- costs were maximized through community en- tional and international standards. gagement and coordination with other local Furthermore, the CCA provided valuable social actors such as the government, nongovern- insights into the realities of WASH conditions and mental organizations, municipalities, and ances- practices in HCFs in the Western Highlands of tral organizations. Guatemala and the risk that inadequate condi- tions pose to individual health and the provision of high-quality health care services. Sustainability The CCA provided Participating HCFs made substantial incre- In May 2019, all 194 United Nations member valuable insights mental improvements and achieved Clean Clinic states voted in favor of a World Health Assembly into realities of certifications. WASH general management stan- resolution for the improvement of water, sanita- WASH and the risk dards improved; toilets and sinks were in optimal tion, and hygiene (WASH) in health care facilities that inadequate condition with water, soap, and hand-drying (HCFs). The resolution reflected the importance conditions pose to towels; and common, special, and infectious waste of improving and sustaining WASH services in im- health. was available and segregated where needed. proving quality of care, achieving universal The categories with the most improvement, WASH and health care coverage as part of the administration, and the least, cleaning, were most Sustainable Development Goals, and slowing the under the control of the HCFs. The reason for the spread of antimicrobial resistance.21 lack of improvement in cleaning was mainly due To ensure the long-term sustainability of the to facilities being unable to develop cleaning CCA, we recommend considering several impor- schedules and protocols within the assessment pe- tant factors. Engage communities in the Clean riod. However, the improvements in administra- Clinic certification process to maintain existing tion coupled with knowledge sharing among the improvements and mobilize resources for im- facilities and incorporation into action plans could provements that require them. Activation and op- facilitate improving assessment scores. eration of Clean Clinic teams in each facility According to feedback received during a should be formalized through administrative pro- knowledge-sharing workshop hosted by MCSP cesses. Ensure integration of both WASH and IPC with participation from national and regional into any and all health care quality improvement MSPAS and HCF staff, the contributing factors to efforts and improve WASH and IPC monitoring the positive outcomes included integration of a and data collection. Comprehensive data are steering team from the central level of the needed for managers to make informed decisions MSPAS; use of an easy to understand assessment on quality improvements and resource allocation. tool for monitoring progress; in-service team Data on health outcomes and associated costs will trainings at the HCFs; technical support provided also allow managers to quantify any time and by MCSP WASH team; and involvement of local resources savings associated with improved MSPAS authorities including hospital, district, WASH and IPC. Plan for operational resources, and regional directors of health. Also, HCF staff supplies, and infrastructure for WASH and IPC in

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the respective annual procurement plans of each WASH quality of care improvements. Training fa- facility along with their corresponding manage- cility staff was fundamental to improving quality ment, similar to how essential medicines are standards, and involving medical and administra- prioritized. tion staff in joint analysis, coordination, and planning sessions was key to integration and Potential Use in Other Contexts teamwork. Further work is needed to increase in- Ministry of Health authorities are interested in volvement of local government and community implementing, updating, using, and improving members and to further adapt the process and the assessment tool for measuring compliance tools. Additionally, the CCA tool can be revised to with quality standards and are currently working encompass primary care facilities and additional toward national implementation of the CCA. services within HCFs. The CCA assessment tool and subsequent stakeholder feedback may also serve as the basis Acknowledgments: We would like to acknowledge the commitment and ’ collaborative spirit demonstrated by the MCSP Guatemala team for developing Guatemala s advanced service members for providing the required support. We would like to express levels of the JMP standards to be defined by each our gratitude to staff and management from participating health facilities for their role in improving WASH for IPC. country. This report was developed using the Standards for Quality in Improvement Reporting Excellence Guidelines (SQUIRE 2.0).22 Limitations Due to the small sample size of the intervention Funding: This article was made possible by the generous support of the American people through the United States Agency for International (11 HCFs), the results are not considered general- Development (USAID) under the terms of the Cooperative Agreement izable. Although measurements were taken at the AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the ward level, the HCF Clean Clinic certification was views of USAID or the United States Government. based on averages across the HCF. This may have had the unintended effect of masking changes Competing interests: None declared. within individual wards. The CCA assessment tool was the same regardless of the type of facility REFERENCES (hospital, CAP, or CAIMI). HCF staff noted that 1. World Health Organization (WHO), United Nations Children’s standards should be tailored to each facility level Fund (UNICEF). WASH in Health Care Facilities: Global Baseline to accommodate their varying circumstances Report 2019. Geneva: WHO and UNICEF; 2019. Accessed while still maintaining service-level standards. November 13, 2019. https://www.who.int/water_sanitation_ health/publications/wash-in-health-care-facilities-global- The intervention focused on improving the report/en/ availability of WASH services and supplies and 2. Cronk R, Bartram J. Environmental conditions in health care facili- did not collect data on intervention-related health ties in low- and middle-income countries: coverage and inequal- outcomes. The intervention did not include direct ities. Int J Hyg Environ Health. 2018;221(3):409–422. CrossRef. patient and visitor engagement, which is a poten- Medline tial point of entry for hygiene improvements that 3. Allegranzi B, Nejad SB, Combescure C, et al. Burden of endemic may contribute to the continued demand for health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet. 2011;377(9761):228–241. Clean Clinic certified facilities. CrossRef. Medline The institutional dynamics of the MSPAS con- 4. Holmes AH, Moore LSP, Sundsfjord A, et al. Understanding the strained CCA implementation due to high staff mechanisms and drivers of antimicrobial resistance. Lancet. turnover, slow administrative processes, lack of 2016;387(10014):176–187. CrossRef. Medline basic and minimum resources (soap and chlorine), 5. World Health Organization, Maternal and Child Epidemiology and the limited human resources spread over Estimation Group (MCEE). Global and regional child deaths by cause. UNICEF DATA. https://data.unicef.org/topic/child- many functions. The intervention did involve survival/neonatal-mortality/. Published May 2, 2019. Accessed municipalities and local health committees that November 13, 2019. are responsible for facility infrastructure at the 6. Bouzid M, Cumming O, Hunter PR. What is the impact of water san- CAP and CAIMI level. No formal or public com- itation and hygiene in health care facilities on care seeking behav- mitment was established with local municipal iour and patient satisfaction? A systematic review of the evidence governments, resulting in their limited engage- from low-income and middle-income countries. BMJ Global Health. 2018;3(3):e000648. CrossRef. Medline ment in the process. 7. Pan American Health Organization (PAHO), Government of Guatemala, Ministry of Public Health and Social Assistance. Results CONCLUSIONS of an Assessment of WASH in Health Care Facilities in Guatemala, completed in 2018 [in Spanish].; Washington DC: PAHO; 2018. The CCA process and tools facilitated a systematic Accessed February 12, 2020. https://www.washinhcf.org/ way for HCFs to prioritize, make, and measure resource/evaluacion-de-la-situacion-de-agua-saneamiento-e-

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higiene-en-establecimientos-de-atencion-de-salud-informe- 16. Gobierno de Guatemala. Politica National del Sector de Agua guatemala/ Portable y Saneamiento. Guatemala City: Government of 8. Tzul AM, Kestler E, Hernández-Prado B, Hernández-Girón C. Guatemala; 2013. Accessed November 19, 2019. https://www. Maternal mortality in Guatemala: differences between hospital and mspas.gob.gt/images/files/saludabmiente/regulacionesvigentes/ non-hospital deaths [in Spanish]. Salud Publica Mex. 2006;48 PolIticalNacionalAPS/PoliticaNacionalSectorAguaPotable (3):183–192. CrossRef. Medline Saneamiento.pdf 17. World Health Organization (WHO). Standards for improving 9. Salvatierra-González RM, ed. Costo de la infección nosocomial en quality of maternal and newborn care in health facilities. Geneva: nueve países de América Latina. Washington, DC: Pan American WHO; 2016. https://www.who.int/maternal_child_adolescent/ Health Organization; 2003. Accessed July 16, 2019. http:// documents/improving-maternal-newborn-care-quality/en/ socienee.com/wp-content/uploads/n_internacionales/ni2.pdf 18. World Health Organization (WHO). Core questions and indicators 10. Deming WE. Out of Crisis, Centre for Advanced Engineering for monitoring WASH in health care facilities in the Sustainable Study. Cambridge, MA: Massachusetts Institute of Technology; Development Goals. Geneva: WHO; 2018. https://apps.who.int/ 1983. iris/bitstream/handle/10665/275783/9789241514545-eng.pdf 11. Huskins WC, Soule BM, O’Boyle C, Gulácsi L, O’Rourke EJ, 19. Ministerio de Salud Publica Y Asistencia Social (MSPAS) de Goldmann DA. Hospital infection prevention and control: a model Guatemala Vice Ministerio de Hospitales. Guía para el control y for improving the quality of hospital care in low- and middle-income prevención de infecciones nosocomiales. Guatemala City: MSPAS; countries. Infect Control Hosp Epidemiol. 1998;19(2):125–135. 2011. Medline 20. Maternal and Child Survival Program (MCSP). Cost Analysis for 12. Varkey P, Reller MK, Resar RK. Basics of quality improvement in Clean ClinicApproach Activities in Guatemala and Implications for health care. Mayo Clin Proc. 2007;82(6):735–739. CrossRef. Scale-Up. Washington DC: MCSP; 2019. Accessed February 19, Medline 2020. https://www.mcsprogram.org/resource/cost-analysis-for- 13. Maternal and Child Survival Program (MCSP), Save the Children. clean-clinic-approach-activities-in-guatemala-and-implications-for- Clean Clinic Approach Brief. Washington, DC: MCSP; 2016. scale-up/ Accessed November 13, 2019. https://www.mcsprogram.org/ 21. UN-Water. Ministers of Health approve resolution on WASH in resource/clean-clinic-approach-brief/ health care facilities. May 2019. Accessed October 31, 2019. 14. Maternal and Child Survival Program (MCSP). WASH for Health https://www.unwater.org/ministers-of-health-approve-resolution- Care. https://washforhealthcare.mcsprogram.org/. Published on-wash-in-health-care-facilities/ 2017. Accessed November 13, 2019. 22. Ogrinc G, Davies L, Goodman D, Batalden PB, Davidoff F, Stevens D. 15. World Health Organization (WHO). Water, Sanitation and Hygiene SQUIRE 2.0 (Standards for Quality Improvement Reporting in Health Care Facilities: Practical Steps to Achieve Universal Access Excellence): revised publication guidelines from a detailed consensus to Quality Care. Geneva: WHO; 2019. https://apps.who.int/iris/ process. BMJ Quality and Safety. 2016; 25:986–992. CrossRef. bitstream/handle/10665/311618/9789241515511-eng.pdf Medline

En español

La implementación del Enfoque de Clínica Limpia mejora la calidad del agua, el saneamiento y la higiene en los establecimientos de salud en el Altiplano Occidental de Guatemala

Principales Conclusiones

 Los servicios de agua, saneamiento, e higiene (WASH) y los suministros de prevención de infecciones son deficientes en los centros de salud guate- maltecos que proporcionan servicios de atención del parto.

 El Enfoque de Clínica Limpia resultó en mejoras significativas en muchos indicadores de preparación para WASH y la prevención de infecciones a pesar de muy poca inversión.

 El éxito y sustentabilidad del proceso del Enfoque de Clínica Limpia se basa en:

8 Establecer estándares claros, concisos y específicos para cada sala;

8 Orientar al personal a sus responsabilidades a medida que se aplican a los estándares provistos;

8 Recopilación de datos detallados a nivel de sala; y

8 Compartir los resultados de las mediciones con el personal de los establecimientos de salud, los gobiernos locales, y el público. Principales Implicaciones

 El uso de intervenciones económicas como el Enfoque de Clínica Limpia puede ayudar a los establecimientos de salud a realizar y mantener mejoras efectivas e incrementales en la preparación para la prevención de infecciones.

 Para fomentar la futura expansión de WASH en los establecimientos de salud, los donantes, y los socios implementadores deben:

8 Colaborar con los ministerios nacionales de salud para revisar y actualizar las pautas nacionales para la prevención y el control de infecciones en los hospitales,

8 Promover la intervención entre los directores de hospitales y las direcciones regionales del ministerio de salud,

8 Asóciese con la administración de los establecimientos de salud para actualizar las herramientas de evaluación de acuerdo con el nivel de atención y el tipo de servicio/sala con consideración para el nivel básico de servicio, y

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8 Amplíe la intervención para incluir más centros de atención médica y comparta los resultados públicamente.

RESUMEN

 Contexto: Los servicios de agua, saneamiento e higiene (WASH) son elementos esenciales para proporcionar servicios de atención médica seguros y mejorar la satisfacción del paciente y la búsqueda de atención de la salud. El Enfoque de Clínica Limpia (CCA) utiliza un proceso de 10 pasos para apoyar a los establecimientos de salud (ES) en la realización de mejoras incrementales y efectivas de limpieza y prevención y control de infecciones, sin depender de inversiones externas. Pusimos a prueba el CCA en Guatemala y evaluamos el grado en que contribuyó a las mejoras de calidad en WASH para prevención y control de infecciones.

 Métodos: Después de desarrollar una herramienta de evaluación adaptada al contexto guatemalteco, evaluamos 11 ES en 8 áreas técnicas y las calificamos en 79 criterios con un total de 100 puntos. Realizamos una medición de referencia (septiembre a octubre de 2018), una segunda medición (enero de 2019) y una medición final (febrero a marzo de 2019).

 Resultados: Los 11 ES mejoraron sus puntajes promedio en la sala de emergencias/general de 41 puntos al inicio del estudio a 87 puntos en la medición final, en base a una escala de 100 puntos. Para salas de parto, los puntajes aumentaron de 50 a 91 puntos y para salas de recién nacidos de 46 a 90 puntos.

 Conclusiones: El proceso y las herramientas del CCA facilitaron una forma sistemática para que los ES identifiquen, prioricen, realicen y midan las mejoras en la calidad de la atención de WASH. La capacitación del personal de las instalaciones fue fundamental para mejorar los estándares de calidad, y la participación del personal médico y administrativo en sesiones conjuntas de análisis, coordinación y planificación fue clave para la integración y el trabajo en equipo. Se necesita más trabajo para aumentar la participación de los gobiernos locales y los miembros de la comunidad y para adaptar aún más el proceso y las herramientas.

Peer Reviewed

Received: November 26, 2019; Accepted: March 4, 2020; First published online: May 21, 2020

Cite this article as: Lopez J, Tumax Sierra S, Cardona AMR, Sara S. Implementation the Clean Clinic Approach improves water, sanitation, and hy- giene quality in health facilities in the Western Highlands of Guatemala. Glob Health Sci Pract. 2020;8(2):256-269. https://doi.org/10.9745/GHSP- D-19-00413

© Lopez et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https:// doi.org/10.9745/GHSP-D-19-00413

Global Health: Science and Practice 2020 | Volume 8 | Number 2 269 ORIGINAL ARTICLE

Evaluating the Implementation of an Intervention to Improve Postpartum Contraception in Tanzania: A Qualitative Study of Provider and Client Perspectives

Kristy Hackett,a Sarah Huber-Krum,a Joel M. Francis,b,c Leigh Senderowicz,a Erin Pearson,d Hellen Siril,b Nzovu Ulenga,b Iqbal Shaha Key Findings ABSTRACT Background: This qualitative study assessed implementation of n Constraints on staff, time, and supplies and the Postpartum Intrauterine Device (PPIUD) Initiative in Tanzania, challenges with referrals influenced a country with high rates of unintended pregnancy and low con- implementation outcomes and threatened traceptive prevalence. The PPIUD Initiative was implemented to sustainability. reduce unmet need for contraception among new mothers through postpartum family planning counseling delivered during n Women reported that interpersonal aspects of antenatal care and offering PPIUD insertion immediately follow- care varied. ing birth. n Providers reported that additional training Methods: We used the implementation outcomes framework and opportunities, improved staffing, and increased an ecological framework to analyze in-depth interviews with pro- availability of PPIUD supplies would strengthen viders (N=15) and women (N=47) participating in the initiative. future initiatives. We applied a multistage coding protocol and used thematic con- tent analysis to identify the factors influencing implementation. Results: Both women and providers were enthusiastic and recep- tive to the PPIUD Initiative. Health system and resource constraints Key Implications made adoption and fidelity to the intended intervention challeng- ing. Many providers questioned the sustainability of the initiative, and most agreed that changes to the initiative’s design (e.g., ad- We recommend that PPFP program imple- ditional training opportunities, improved staffing, and availability menters consider: of PPIUD supplies) would strengthen future iterations of the initia- tive. According to women, interpersonal aspects of care varied, n Assessing the feasibility of integrating PPFP with some women reporting rushed or incomplete counseling or counseling into existing antenatal care services an emphasis on the PPIUD over other methods. The perception before program implementation that some providers treat older married women more favorably suggests that fidelity to the intended PPIUD Initiative was not uni- n Ensuring that future initiatives emphasize patient- formly achieved. centered PPFP counseling, informed choice, and Conclusions: Study findings inform initiatives seeking to develop respectful and nondiscriminatory service delivery and adopt postpartum family planning programs and enhance n Implementing a stronger interfacility performance program implementation. A comprehensive needs assessment to and quality improvement system to strengthen evaluate feasibility and identify potential adaptations for the local coordination context is recommended. Training and supervision to improve interpersonal aspects of care, including an emphasis on patient- n Using different models of PPFP counseling to centered counseling, informed choice, and respectful and help alleviate provider workload nondiscriminatory service delivery should be integrated into fu- ture postpartum family planning initiatives.

INTRODUCTION nintended and mistimed pregnancies are pressing a Department of Global Health and Population, Harvard T.H. Chan School of U Public Health, Boston, MA, USA. global public health concerns due to their associa- b Management and Development for Health, Dar es Salaam, Tanzania. tions with increased maternal, newborn, and child – c Department of Family Medicine and Primary Care, School of Clinical Medicine, morbidity and mortality.1 4 The postpartum period Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. represents a critical window of opportunity to ensure d Technical Innovation and Evidence, Ipas, Chapel Hill, NC, USA. healthy timing and spacing of subsequent pregnancies 5 Correspondence to Kristy Hackett ([email protected]). and to address unmet need for family planning.

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Despite increased attention to the postpartum Recent improvements in institutional delivery period as an opportunity for family planning inter- rates across sub-Saharan Africa14 make prenatal ventions, recent estimates from 57 countries show contraceptive counseling and PPIUD a promising that 62% of women have an unmet need for PPFP option among populations likely to receive contraception immediately after delivery, and ANC and/or deliver in facilities but unlikely to 40% have an unmet need within the first year af- return for care in the postpartum period. In ter birth.6 Postpartum family planning (PPFP) Tanzania, institutional delivery rates have in- initiatives that respect women’s right to make full creased substantially in recent decades (44% to 63% between 1999 and 2016) and uptake of and informed choices have the potential to help ANC from a skilled provider is almost universal meet these needs. (98% in 2016), yet PNC coverage has been slow Where available, PPFP counseling is part of to improve.15 Only 37% of mothers receive a post- postnatal care (PNC) services.7 However, PPFP natal checkup after their most recent live birth15 counseling is not consistently provided, and PNC and the quality of postnatal services is often low.16 often disproportionally focuses on the well-being Therefore, providing prenatal contraceptive of the newborn rather than the mother. Addi- counseling and offering PPIUD insertion is a tionally, in many low-income settings, a host of desirable intervention in Tanzania, where the socioeconomic obstacles prevent mothers from government recently committed to increasing the returning to facilities for postnatal check-ups; availability of modern contraception at all levels of therefore, opportunities for PPFP are often the health system from 40% in 2012 to 70% by missed.8 One strategy to overcome this challenge 2020.17 Tanzania’s modern contraceptive preva- is to provide PPFP counseling during antenatal lence rate (mCPR) is 31%, and more than a quar- care (ANC), which is more widely used than PNC, ter of reproductive-age women have an unmet followed by immediate insertion of the intrauter- need for modern contraception.17 Despite the ine device (IUD) after delivery (within 10 minutes known benefits of PPIUD, uptake of the IUD, re- following delivery of the placenta or within gardless of insertion timing, is low in Tanzania 48 hours) to women who opt for this method. (less than 1% among reproductive-age women).15 The copper IUD is widely accepted as an effective, Programs providing PPIUD services are just begin- long-acting (up to 12 years), reversible method ning to emerge in low- and middle-income coun- of contraception and is particularly convenient tries (LMICs); consequently, there is a gap in the when inserted immediately after birth.9 Other literature on PPIUD programs, with few published benefits of the postpartum IUD (PPIUD) are that evaluations and limited research on implementa- it can be inserted after either vaginal or cesarean 18 tion processes. This study helps to fill this gap delivery, does not interfere with breastfeeding, by assessing the factors influencing implementa- and can be used by women who have HIV.9 tion of a novel PPIUD Initiative in Tanzania. Several systematic reviews have established the safety and effectiveness of PPIUD insertion.10,11 Immediate PPIUD insertion is a specialized PPIUD INITIATIVE DESCRIPTION AND technique that differs from interval IUD insertion, ACHIEVEMENTS and thus requires additional hands-on didactic In 2013, the International Federation of Gyne- training and specialized equipment.12 Due to the cology and Obstetrics (FIGO) launched an initia- early postpartum timing of the procedure and the tive to institutionalize PPIUD services in Sri rapid change in the uterus during this time, expul- Lanka, followed by Tanzania, Nepal, India, sion rates for immediate PPIUD insertions are Kenya, and Bangladesh in 2015.19 Through this higher than for interval insertions.12 According to initiative, clinic and hospital staff in select facilities a recent review, expulsion rates vary by timing of received training on the provision of PPFP IUD placement, ranging from 1.9% with interval counseling and PPIUD insertion techniques as placements (greater than 4 weeks postpartum), novel services. To promote sustainability, the proj- 10.0% for immediate placements within 10 min- ect was designed for implementation within exist- utes following placental delivery, and 29.7% for ing maternity services, and current staff were placements between 10 minutes to 4 weeks post- intended to deliver PPFP counseling and PPIUD partum.13 For these reasons, it is recommended insertion rather than recruiting new health work- that women who opt for PPIUD insertion are ers. Facilities were selected on the basis of having a counseled regarding the increased expulsion risk, large annual obstetric caseload (>5000 deliveries), as well as signs and symptoms of expulsion.12 a large number of providers and medical trainees,

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and no PPIUD services already provided.19 In each During counseling training, trainers presented country, the project was implemented through detailed information on all available methods in- national pro-fessional societies or colleges to en- cluding PPIUD. Providers were encouraged to courage ownership by in-country obstetricians share their opinions on PPIUD so that underlying and gynecologists. Although the project design prejudices could be addressed.19 Training sessions and budget allowed for country-specific tailoring, were interactive and included role-play with case the same general model was implemented in each scenarios of women with different family plan- country. This model included a dedicated project ning needs. Staff were encouraged to use learning management team, a coordinator at each partici- aids (leaflets, posters, flipcharts, and videos) to en- pating facility, a Data Safety Monitoring hance PPFP counseling sessions. Committee, and national steering groups who Providers at satellite clinics were trained on provided clinical and technical guidance.19 PPFP counseling only, but had the opportunity to Further details on the PPIUD Initiative design and observe and perform practice insertions on Mama- components are published elsewhere.19 We pre- U models during their training. Those working sent key elements and inputs of the PPIUD in selected tertiary/teaching hospitals received Initiative in Table 1 and summarize intervention additional off-site training on PPIUD insertion. components at the provider and client levels in Providers were trained to counsel women during Figure 1. routine ANC and at labor and delivery. Training covered the benefits and side effects of PPIUD and Tanzania PPIUD Initiative all other methods, as outlined in Tanzania’s na- 20 In Tanzania, the PPIUD Initiative was first imple- tional PPFP guidelines. Trainers also emphasized mented in 6 hospitals. However, 1 facility was the voluntary nature of the program—that wom- dropped because it had an ongoing PPIUD inter- en have the option to opt in or out of PPIUD inser- vention. Therefore, the study was conducted in tion both pre- and postpartum. 5 hospitals. FIGO and their local affiliate, the PPIUD insertion and removal training includ- Association of Gynecologists and Obstetricians of ed both classroom-based theoretical training and Tanzania (AGOTA): (1) trained maternity care practical sessions using the Mama-U postpartum providers at tertiary/teaching hospitals on PPFP uterus, an anatomical model intended for clinical counseling, PPIUD insertion techniques, and com- training purposes. The technique taught used the plications management; (2) hosted informational long-handled 33 cm curved Kelly forceps to en- workshops for nurses and midwives at satellite sure that the IUD was placed at the top of the clinics on PPFP counseling techniques; (3) provid- fundus while the uterus is still enlarged as opposed ed PPFP leaflets to be distributed during counsel- to 24 cm tissue or sponge forceps, which do not ing; (4) provided a video to be played in hospital reach the fundus and may lead to higher expul- 19 waiting areas; (5) supplied Kelly forceps for vagi- sion rates. Assessment of trainee competency nal PPIUD insertion; and (6) conducted regular following PPIUD insertion training was standard- monitoring and support. ized across countries. To achieve competency, trainees had to successfully complete a minimum Provider Training of 3 peer-assessed Mama-U insertions, 2 super- vised live insertions, and 3 unsupervised live The PPIUD Initiative applied a “train-the-trainer” insertions.19 approach whereby a group of master trainers were identified in each country, trained providers on PPFP counseling and PPIUD insertion, and Program Implementation then those providers were expected to cascade Women attending ANC at satellite clinics were training to other staff after returning to their hos- intended to receive one-on-one PPFP counseling. pital. Master trainers were accredited by the In accordance with national PPFP guidelines Tanzania Ministry of Health and Social Welfare. around informed choice,20 counselors were All providers eligible to insert IUDs were to receive expected to deliver information about all avail- training, and refresher trainings were to be con- able family planning methods, including how ducted as needed. Three days of training were they work, duration of use, effectiveness, and dedicated to counseling, and 3 days to insertion. possible side effects. Women had the choice of During the 6-day training period, providers re- method, and all methods were available free of ceived a daily allowance of the equivalent to cost. Available methods included condoms, oral US$55 to cover the cost of lodging and meals. contraceptive pills, emergency contraceptives,

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TABLE 1. Key Elements and Inputs Intended for Implementation of the PPIUD Initiative in 6 Countries

Elements and Inputs Description

Training: “Train-the-trainer” model: Training cascaded from Counseling: master trainers to existing eligible providers at selected  Prenatal counseling on available family planning methods with an emphasis health facilities on PPFP using standard training methods (e.g., GATHER model)  Included information on the advantages of PPIUD  Open discussion about providers’ views of PPIUD to address any prejudices  Role play, case scenarios  Providers encouraged to use counseling aids (e.g., leaflets, posters, flipcharts, and videos) PPIUD insertion and removal:  Theoretical (classroom-based) training and practical sessions using Mama-U postpartum uterus models  Refresher trainings offered as needed  Regular training of new staff rotating in

Equipment and supplies  Mama-U models  Copper T IUDs  Long-handled 33 cm curved Kelly forceps

National coordination  Implementation was coordinated through national professional societies or colleges to encourage local ownership  National societies set up steering groups for clinical and technical guidance

Structures established to facilitate implementation  Dedicated project management team  Facility-level project coordinators  Data Safety Monitoring Committees

PPIUD counseling and insertion services delivered by trained  Integrated within existing maternity services providers  Prenatal counseling on all available contraception methods with an emphasis on PPFP, and the advantages of PPIUD as a safe, effective, and reversible long-acting method  Consent forms provided during prenatal visits  Stickers placed on women’s case files to identify consenting women at delivery  Women who did not receive prenatal counseling could be counseled during early labor or the postnatal period to ensure insertion within 48 hours if PPIUD was desired

Monitoring and evaluation  Data collection officers collected information on counseling, consent, PPIUD, and follow-up for women delivering in participating facilities

Abbreviations: GATHER, greet, ask, tell, help, explain, and return; IUD, intrauterine device; PPFP, postpartum family planning; PPIUD, postpartum intrauterine device.

natural family planning methods, injectables, who received counseling during ANC visits had implants, IUDs, and voluntary surgical steriliza- the option to provide advance consent to PPIUD tion.20 Within the range of methods described, insertion after delivery, and their medical charts providers emphasized the advantages of PPIUD were marked with their stated decision. Those as a safe, effective, and long-acting method.19 who opted for PPIUD in advance were referred They were also expected to demonstrate how to a tertiary/teaching facility for delivery, where the PPIUD is inserted using visual aids, bro- trained providers would insert the PPIUD. chures, and anatomical models. Pregnant women Women who consented during pregnancy were

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FIGURE 1. Provider- and Client-Level Interventions for the PPIUD Initiative

Abbreviations: AGOTA, Association of Gynecologists and Obstetricians of Tanzania; FP, family planning; IUD, intrauterine device; ob/gyn, obstetrics/gynecology; PPFP, postpartum family planning; PPIUD, postpartum intrauterine device.

asked again at the time of delivery to confirm AGOTA’s routine monitoring, trained data collec- their choice of PPIUD insertion, at which point tion officers conducted exit interviews with all they could refuse PPIUD without consequence. consenting women after delivery and before dis- Additional counseling on other family planning charge. These interviews captured data on wheth- methods was available to all women. Women er women received PPFP counseling, and whether who received a PPIUD were advised to return for they consented to having PPIUD inserted. Third, afollow-upvisitat6weekspostpartumtoensure the Tanzania Data and Safety Monitoring Board proper placement of the IUD. In some cases, IUD reviewed progress semiannually. Fourth, a steer- threads were trimmed at follow-up if women ing committee comprised of experienced gynecol- complained of feeling them or reported discom- ogists and the national coordinators provided fort during intercourse. high-level oversight. Providers who had difficul- Four levels of supervision and quality assur- ties with their insertion technique received quar- ance were put into place. First, facility-level coor- terly refresher trainings throughout the initiative. dinators provided weekly supervision. Second, Key achievements of the PPIUD Initiative in the AGOTA monitoring and evaluation team con- Tanzania are summarized in Table 2. A prospec- ducted quarterly supervision visits. As part of tive cohort study nested within Tanzania’s PPIUD

TABLE 2. PPIUD Initiative Achievements in Tanzania

Achievements

Participating hospitals, n 6 Providers trained under the PPIUD Initiative, n 827 Women counseled on family planning and PPIUD, n 21,479 Counseled during antenatal care, % 57.0 Counseled only after admission for delivery, % 43.0 Deliveries during the PPIUD Initiative period, n 91,387 Women followed up for postpartum interview, n 80,194 Women who consented for PPIUD insertion, n 5,634 PPIUD insertions, n 3,095

Abbreviation: PPIUD, postpartum intrauterine device.

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Initiative reported that 5.8% of women who de- present study, we conducted qualitative in-depth livered at project hospitals during the study period interviews (IDIs) with providers and women who had a PPIUD inserted.21 Forty-three percent of participated in the initiative to assess the imple- women with a PPIUD returned to a project- mentation barriers and facilitators. affiliated clinic for follow-up visit 4–6 weeks after The consolidated criteria for reporting quali- delivery. Among them, midwives performed tative research (COREQ) was used to ensure 59% of PPIUD insertions, and clinicians per- complete reporting of qualitative procedures formed 41%. PPIUD expulsion and removal rates (Supplement 1). Sample sizes for IDIs were esti- were 1.2% and 8.3%, respectively.21 mated based on what would be sufficient to achieve saturation in themes and study aims.24 Parent PPIUD Study Authors recruited and trained 2 female Tanzanian This qualitative investigation was nested within interviewers, who were hired as independent con- ’ the Tanzania PPIUD parent study, which evaluat- sultants. The interviewers each had bachelor s ed the causal effect of the initiative on the uptake degrees in sociology and more than 10 years’ expe- and subsequent continued use of PPIUD in rience conducting qualitative interviews. Authors 3 countries: Nepal, Sri Lanka, and Tanzania. The oriented the interviewers on study procedures study in Tanzania was conducted in tertiary/ including the ethical considerations, informed teaching hospitals in 5 cities: Arusha, Dodoma, consent process, and interview guides, as well as Dar es Salaam, Mbeya, and Pwani. A hospital oversaw piloting and data collection. The inter- and 3–4 of its satellite clinics were selected in viewers had no prior relationship to study partici- each location (see research protocol for detailed pants, and participants had no prior knowledge of 9 procedures). any research team members. In the parent study, the PPIUD initiative had We conducted IDIs with 15 providers between only a modest impact on women’s choice of June 2016 and February 2017, approximately PPIUD (an increase of 6.3 percentage points) due 3 months after they received PPIUD training, to to low coverage of PPIUD counseling among wom- understand their experiences with the training 22 en delivering in study facilities. Adherence- and perceived facilitators and barriers to imple- adjusted estimates suggest that if all women had mentation. We purposively selected 2–4 providers been counseled as intended, we could expect a from each hospital who had participated in the 31.6 percentage point increase in choice of training and were actively delivering the initia- PPIUD. Qualitative findings from the present tive. Researchers contacted providers by phone study are intended to contextualize these results to inform them about the interviews, briefly ex- by highlighting strengths and weaknesses in pro- plain the purpose of the interviews, and request gram implementation and potential opportuni- participation. ties to improve future implementation of similar We conducted IDIs with 47 women exposed to interventions. the initiative to understand their experiences with Identifying factors that influence program im- PPFP counseling, and their decision making re- plementation is essential for assessing the fidelity garding postpartum contraceptive use. Between of interventions and understanding why they June 2016 and February 2017, we conducted IDIs were or were not effective. For example, negative with 20 pregnant women who had at least 2 ANC results can occur when interventions are not imple- visits in a study facility, received PPFP counseling, mented sufficiently, and similarly, positive results and were offered PPIUD insertion. From each site, can be achieved by an intervention that was we purposively sampled 4 pregnant women to in- delivered differently than intended.23 Therefore, clude a mix of women from higher- and lower- understanding what contributes to implementation income levels and range of ages. Eligible women success or failure is critical to program improvement, were initially approached by providers at the end replication, and scale-up across settings. of their ANC appointment to inform them about the study. Women who were interested to learn METHODS more were referred to the research team. Inter- viewers assessed women’s eligibility independent Study Design and Data Collection Procedures of providers, explained the purpose of the study, One objective of the evaluation was to understand administered informed consent, and conducted how the initiative was implemented, the perspec- private one-on-one interviews after an ANC visit. tives of providers on implementation, and recep- Between April 2018 and August 2018, we tiveness of women toward PPIUD services. In the interviewed a separate sample of 27 postpartum

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women who had received a PPIUD. The parent Ethics Approval and Consent to Participate study collected data on whether women contin- Ethical approval as exempt was granted by the ued using the PPIUD, discontinued due to Institutional Review Board at Harvard University. expulsion, or intentionally discontinued before The study received ethical approval from the the qualitative interviews. We aimed to recruit National Health Research Ethics Review Com- 10 women from each of these groups; however, mittee of the National Institute of Medical the number of women who experienced expul- Research in Tanzania. The consent statement in- sion was small (1.2% in the parent study), thus cluded the purpose of the study, confidentiality of we were only able to recruit 7 women. These personal information, and the use of information women were randomly selected for interviews for publication. Only those who consented were from the parent study database, which included interviewed. detailed contact information for enrolled women. Researchers contacted women by phone to inform them about the qualitative interviews, briefly ex- Analytical Strategy We used ATLAS.ti (Version 8.0) to manage, code, plain the purpose of the interviews, and request participation. and interpret transcripts using thematic content analysis. We applied a multistage analytical strate- We developed semistructured interview guides 26 with open-ended questions in English and translat- gy to identify key themes, codes, and subcodes. ed them into Swahili. The interview guide for In the first stage, we prepared an initial list of par- providers covered the following topics: knowledge, ent codes and definitions based on study aims, in- experiences, and preferences for contraceptive terview guides, and existing literature on PPFP. methods; PPIUD training experience; and imple- Examples of parent codes include: counseling im- mentation, scale-up, and diffusion of PPIUD plementation, IUD, other family planning meth- services. Interview guides for women included ods, decision making, and quality of services. We questions to assess contraceptive knowledge and applied these high-level codes to group the data 26 prior use, as well as their experiences and percep- in our first pass through the transcripts. During tions of PPFP counseling and postpartum contra- this process, we identified relevant subcodes un- ceptive decision making. For postpartum women der each parent code. For example, under the “ ” who received a PPIUD, the guide included ques- counseling implementation code, we added the tions regarding their experience with the PPIUD following subcodes: client receptiveness, counsel- Initiative, including content and perceived quality ing frequency, counseling content, counseling “ of PPFP counseling. We also asked questions about provider, and counseling timing. Under decision their experiences using the PPIUD, including rea- making” we identified the following subcodes: sons for continuation or discontinuation. Tanzanian support, trust, method choice influence, discon- researchers verified translations and back-translated tinuation, fertility limit, fertility space, fertility the guides to ensure content and semantic equiva- continue, coercion, and trade-offs. We developed lence of each question.25 We pretested interview a preliminary codebook, which included both pre- guides to assess question phrasing, sequencing, and determined and emergent codes. Next, we divided overall comprehension and modified the guides as the transcripts between researchers and indepen- appropriate. dently coded line-by-line using the codebook. We Before each interview, participants were asked wrote analytical memos to summarize case details, to provide written consent to take part in the study. highlighting particularly rich narratives and emer- Women who were unable to sign their names pro- gent themes. We reviewed each other’s coding vided a thumbprint along with a witness’ signature. and came to agreement on categories and themes All providers gave a signature. One-on-one inter- to ensure analytical rigor and consistency across views were conducted in Swahili, and in a private transcripts.26 space at the facilities or another private location if In the final stage, we analyzed the coded participants preferred. Interviewers made field transcripts using 2 theoretical frameworks (de- notes during interviews that were used during scribed later) to answer the following questions: transcription/translation to add contextual details. (1) What were the barriers to, and facilitators of, Interviews were audiorecorded with participants’ PPIUD implementation? and (2) At what level did permission and subsequently transcribed and tran- each of these barriers and facilitators operate? To slated to English for analysis. Interviews lasted do this, we sorted coded sections of the transcripts between 60 to 90 minutes. No one refused to par- into “bins” that correspond to elements of each ticipate in the study. framework. This process was done manually in

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Microsoft Excel to enable visualization of the health system, community, and policy. Imple- sorted data in a matrix. We then analyzed all the mentation of novel interventions is intrinsically quotes within each element/level of the frame- multifaceted, thus it is important to measure out- works to further categorize them into barriers or comes at different levels to understand areas of facilitators. success and failure and potential opportunities for improvement. Yet, few studies specify the level Theoretical Frameworks and rarely address how different levels relate to one another.27 Thus, the ecological framework is To gain insight into the successes and challenges of a useful tool to guide our assessment of this PPFP the PPIUD Initiative’s implementation, we applied initiative by highlighting the contextual, health the implementation outcomes framework devel- 27 system, and policy-level factors that influenced oped by Proctor and colleagues. The framework implementation. differentiates between 3 “distinct but interrelated” sets of outcomes: implementation, service, and cli- ent outcomes. Implementation outcomes are de- RESULTS fined as27: Demographic characteristics of women and provi- ders are summarized in Tables 3 and 4. Analyzing the effects of deliberate and purposive actions to implement transcripts using the 2 frameworks described ...... new treatments, practices, and services, which serve revealed a number of factors that influenced as necessary preconditions for attaining subsequent PPIUD implementation. In Figure 3, we summa- desired changes in clinical or service outcomes rize findings by level in the ecological framework downstream. and include these summaries in the descriptor Figure 2 shows a visual representation of the boxes for each level. In the text that follows, we framework developed by Proctor et al. Applica- apply the Proctor framework to categorize these tion of this framework helps advance our theoret- factors as barriers and facilitators under imple- ical understanding of the implementation process mentation outcomes, service outcomes, and client 27 of the PPIUD Initiative in Tanzania and evaluate outcomes (Table 5). Illustrative quotes are in- the drivers of successful implementation using cluded in the text, and additional quotes are in common nomenclature and a systematic analyti- Supplement 2. We did not find any meaningful ’ cal approach. differences in women s perceptions of how the in- In conjunction with the implementation out- tervention was implemented by age, sociodemo- comes framework, we used an ecological frame- graphic status, or location. work adapted by the United States Agency for International Development’s Maternal and Child Implementation Outcomes Health Integrated Program for PPFP,28 to catego- Acceptability rize factors influencing implementation into 5 dif- Acceptability refers to the perception among im- ferent levels: individual (woman), partner/family, plementation stakeholders that an intervention is

FIGURE 2. Visual Representation of the Implementation Outcomes Framework27

aInstitute of Medicine standards of care.

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TABLE 3. Number and Percent Distribution of Women, by Background Characteristics and Interview Type

Interviews With Pregnant Women Interviews With Women Receiving PPIUD n (%) n (%)

Geographical region Mbeya 3 (15) 9 (33) Arusha 6 (30) 5 (19) Dodoma 2 (10) 4 (15) Dar es Salaam 5 (25) 6 (22) Pwani 4 (20) 3 (11) Age, years <20 1 (5) 1 (4) 20–24 3 (15) 3 (11) 25–29 10 (50) 13 (48) 30–34 3 (15) 2 (7) 35–42 2 (10) 7 (26) Missing 1 (5) 1 (4) Education Some Primary 1 (5) 0 (0) Completed Primary 3 (15) 6 (22) Some Secondary 3 (15) 1 (4) Completed Secondary 10 (50) 15 (56) More than Secondary 2 (10) 4 (15) Missing 1 (5) 1 (4) Marital Status Married 15 (75) 21 (78) Single, not living together 2 (10) 3 (11) Single, living together 1 (5) 0 (0) Widowed 0 (0) 2 (7) Missing 2 (10) 1 (4) Occupation Unemployed 5 (25) 6 (22) Homemaker 1 (5) 0 (0) Business owner 5 (25) 9 (33) Teacher 2 (10) 4 (15) Other (e.g., nurse, secretary, salonist) 5 (25) 7 (26) Missing 2 (10) 1 (4) Religion Christian 15 (75) 20 (74) Muslim 3 (15) 6 (22) Missing 2 (10) 1 (4) Continued

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TABLE 3. Continued

Interviews With Pregnant Women Interviews With Women Receiving PPIUD n (%) n (%)

Total No. of Children (alive or deceased) 0 6 (30) 0 (0) 1 8 (40) 11 (41) 2 2 (10) 7 (26) 3 or more 3 (15) 8 (30) Missing 1 (5) 1 (4)

Abbreviation: PPIUD, postpartum intrauterine device.

“agreeable, palatable, or satisfactory” and can be A policy-level barrier to implementation was a assessed qualitatively based on individuals’ opin- lack of support from local health authorities. ions of the intervention’s content, complexity, or According to a provider, the district reproductive comfort.27 We identified a majority of these fac- and child health coordinator imposed administra- tors at the health system level. tive hurdles to timely implementation, noting that Facilitators. The most important facilitator of it was difficult to convince the coordinator of the intervention acceptability at the health system intervention’s value, which, in turn, delayed the level was high satisfaction with the PPIUD training process of obtaining the necessary equipment in among providers. Providers were highly content time. This suggests that while acceptability was with the training in terms of the content covered, high among training recipients, it was lower complexity of information provided, and comfort among administrative authorities who played a in implementing the skills they learned. One par- key role in implementation. ticipant articulated this particularly clearly, and most providers shared these views: Adoption Implementation was good ...I can say motivation was Adoption is defined as a provider’s “intention, high because of the way training was conducted. It initial decision, or action to try or employ” an equipped people with knowledge and each person intervention.27 came out feeling that she is capable of doing PPIUD Facilitators. Increased confidence among insertion.—Provider providers following the PPIUD training was a key Barriers. Both women and providers reported facilitator of adoption. Although some providers that too few staff were trained specifically on IUD felt the training could be longer, almost all claimed insertion. The limited number of trained inserters that they left the training with new knowledge. was perceived as a missed opportunity, creating Many reported increased confidence in their abili- additional barriers for women seeking PPFP ser- ty to offer family planning counseling and educa- vices. For example, some women consented to tion because of the training received: PPIUD insertion during ANC but failed to have I was not competent with family planning [prior to the the method inserted due to lack of available training], but I was able to learn about the other meth- trained providers: ods too because we were taught briefly [about all meth- More providers should be trained on PPIUD ods] during the training. I came out feeling that I am insertion ...a woman that I advised to get the PPIUD - capable of caring for a woman and all challenges that when she went to the hospital, the health provider who may come up, and all the misconceptions related to could provide the service was not around that day. Many IUD. —Provider women may be discouraged if they experience this. For a Barriers. A commonly cited barrier to PPIUD better service, we need providers that can give the ser- counseling adoption was time constraints among vices whenever needed. —Woman, postpartum already overburdened staff. Despite their satisfac- One provider who was trained only on PPFP tion with training content, some counselors had counseling expressed a desire for additional train- insufficient time to implement what they had ing on insertion. learned.

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Due to time limitations, you ask a woman if she has ever TABLE 4. Number and Percent Distribution of received any counseling previously. If yes, then you only Providers by Background Characteristics focus on the key points because we know she has received information from the antenatal clinic. So we emphasize Characteristic n (%) the advantages of birth control, minor side effects and — Geographical Region their symptoms. Provider Mbeya 4 (27) Providers also described gaps in the referral Arusha 4 (27) system between satellite clinics and larger referral hospitals. Within this system, PPIUD insertion Dodoma 2 (13) providers relied on satellite clinic nurses to pro- Dar es Salaam 2 (13) vide high quality PPFP counseling, make appro- Pwani 3 (20) priate referrals, and provide timely follow-up care, which was not always implemented as Gender intended: Male 2 (13) We often say tragedies that occur in the referral hospitals Female 13 (87) are caused by facilities at the lower level. ...This is Age due to the nurse’s carelessness, perhaps not doing 29–39 7 (47) their job well. If people don’t get proper counseling 40–50 4 (27) at the clinic, we will end up having problems here (at the hospital). —Provider >50 2 (13) Missing 2 (13) Although the PPIUD referral system was intended to streamline project implementation, Profession several hospital-based providers felt there was lim- Physician 3 (20) ited oversight of providers in smaller clinics. One Nurse 12 (80) provider was particularly concerned about 6-week follow-up procedures, in which women were ad- Length working in profession, years vised to return to the hospital to have the IUD ≥ 5 5 (33) placement checked and threads shortened if neces- 6–15 4 (27) sary. According to a provider, if a client returned to ≥16 3 (20) a facility that was unable to provide quality follow- up care, then she may have had a negative experi- Missing 3 (20) ence and discouraged others from adopting PPIUD. Length providing family planning services, years ≥5 5 (33) Fidelity 6–10 7 (47) Fidelity is the degree to which an intervention ≥11 1 (7) was implemented as initially intended by design. Providers described several adaptations to the Missing 2 (13) intended PPIUD intervention, primarily in re- sponse to barriers related to adoption. Barriers. To cope with time and staff short- Time constraints were compounded by short- ages in facility staff, and as a result, PPFP counsel- ages, providers invited pregnant women to attend ing was often deprioritized or adaptions were scheduled group PPFP counseling sessions rather made to ease provider workload. Time constraints than the intended one-on-one counseling during were particularly problematic when women re- ANC visits. Shifting to group counseling helped to ceived PPFP counseling at the time of hospital ad- reduce the burden on busy providers, but social mission before delivery, which may have led to dynamics between older and younger women rushed and/or incomplete counseling. To cope may have influenced some women’s willingness with time constraints at the time of delivery, a pro- to fully participate: vider described a process of triaging patients for PPFP counseling based on previous exposure to Although counseling women as a group is good, I think information. If a woman received PPFP counseling there is also a need to have individual sessions where a during pregnancy, then providers streamlined the woman can ask [her own] questions. Some women, es- topics discussed: pecially those who are old like me, may fail to ask

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FIGURE 3. Ecological Framework Illustrating Factors That Influenced Implementation of the PPIUD Initiative in Tanzania

Abbreviations: PPFP, postpartum family planning; PPIUD, postpartum intrauterine device.

questions when they are in a group of young women, of PPFP options, including their benefits and po- some of whom are teenagers. —Woman, postpartum tential side effects. However, women’s narratives demonstrated that PPFP counseling was highly Although providers considered group family skewed toward PPIUD, and some may have re- planning counseling to be an effective time man- agement strategy, they also acknowledged that it ceived incomplete information (or could only re- was difficult for some women to attend at the call partial information) on the possible physical specified times due to competing household side effects of the PPIUD. This suggests a lack of fi- demands. Since it was not feasible for providers to delity to the training delivered. deliver comprehensive one-on-one counseling [The nurses] told us it works for 10 to 12 years’ time and throughout the day, women who were unable to can be inserted just after delivery ... and you may re- attend group sessions or who arrived late would move it at any time. And this method has no side effects miss counseling completely; a deviation from the unlike implants, which may cause long term bleeding or intended intervention. This challenge was linked lack of menstruation at all. But these new methods, you to diminished motivation, rushed counseling, will still have your menstrual cycle as usual and have no and/or missed counseling opportunities: side effects. Unpleasant effects can occur for the first 3 months but not longer. –Woman, prenatal The nurses are overwhelmed and tired. There are days that you go to the clinic to get services, but you leave without getting educated or counseled on anything. Yet, Penetration when women gather at the clinic that is the best Proctor et al. define penetration as the “integra- platform to explain about the methods for family tion of a practice within a service setting and its planning ... When the woman goes back home, she subsystems.”27 Penetration is closely related to will appreciate that she has learned something and the concept of “diffusion” and is typically mea- when she delivers, she will have already decided on sured quantitatively; however, qualitative analy- — which family planning method to use. Woman, sis revealed important insights into how the postpartum initiative could be better integrated into existing Lastly, counselors were trained to counsel on service delivery environments. Here, we consider all available methods to enable informed choice penetration to include diffusion of the initiative and ensure that women understand the full range both within participating intervention facilities

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TABLE 5. Application of the Implementation Outcomes Framework to Assess Facilitators and Barriers to PPIUD Initiative Implementation in Tanzania

Outcome and Definition Facilitator Barrier

Implementation Outcomes Acceptability: Perception among stake-  High satisfaction with PPIUD training  Lack of providers trained on PPIUD insertion holders that intervention is acceptable (e.g.,  Lack of support from local health authorities satisfaction with PPIUD training content, complexity, comfort) Adoption: Initial implementation of PPFP  Increased confidence following PPIUD  Time constraints and inadequate staffing counseling and PPIUD insertion; Intention to training  Gaps in referral system between satellite clinics try and hospitals

Fidelity: Delivered counseling as intended  Individual counseling replaced by group (e.g., reach, content, and target counseling population)  Diminished provider motivation  Counseling rushed or skipped  Skewed or incomplete counseling

Penetration: Diffusion of PPIUD Initiative  Emphasis on PPIUD’s mechanism of  Objections from faith-based facilities within intervention facilities and to other pregnancy prevention during training  Expectation for remuneration among staff who non-intervention sites did not receive initial training

Sustainability: Long-term maintenance and  Support for population policies and  Breakdown of supply chain and stock-outs institutionalization of the PPIUD Initiative family planning programs to achieve fertility reduction goals

Service Outcomes Equity: Extent to which the PPIUD  Differential treatment by health care providers implementation is equally available/  Financial barriers to accessing hospitals accessible to all intended beneficiaries  Lack of community-based PPFP counseling and services

Client Outcomes Client receptiveness/demand for services:  Level of support from husband/partner  Fear of insertion, concerns related to sexual Client receptiveness to being counseled on  Shared intention among couples to experiences postinsertion, unexpected PPFP and/or demand for receiving the space pregnancy for financial reasons expulsion and experience of unanticipated PPIUD side effects (results published elsewhere26).  Community and gender norms related to birth spacing  Community diffusion of preference for PPIUD and peer recommendation  Women's trust in provider advice  Cost-free counseling and insertion services

Satisfaction with PPIUD services:  Delivery of counseling and services by  Perceived provider incompetence Client receptiveness to being counseled on female provider PPFP and/or receiving PPIUD; Satisfaction  Interpersonal aspects of care with counseling and services

Abbreviations: PPIUD, postpartum intrauterine device; PPFP, postpartum family planning.

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and to other local facilities not selected for the Facilitators. Most health care providers be- PPIUD Initiative. lieved there was strong political will among gov- Facilitators. When service providers reflected ernment officials to invest in strategies that would on the potential for diffusion of the initiative to achieve fertility reduction goals. This was viewed other facilities, they identified a number of factors as a policy-level facilitator of PPIUD sustainability operating at the health system level. One provider beyond the life of the project: explained that receiving focused training on the I don’t see any reason why it would fail because we have PPIUD’s mechanism of action clarified their a problem of high population, and we have an interven- misconceptions about how PPIUD functions and tion that can reduce this population growth rate, so why relieved moral concerns about providing the can’t the government support this? ...If they are able to method: supply other services then why not this as well ...it’sa I heard from Catholics that using loops is killing chil- national priority, and it is in the sustainable develop- dren and you are killing every month, so that thinking ment goals! ––Provider affected me ... Well according to the training it is not Barriers. A key driver of successful institu- true ...[Prior to PPIUD training] when I was advising tionalization at the health system level was having the woman about the methods, afterwards I regretted the necessary instruments and equipment readily that, thinking, “my God, I might have killed” ...I per- stocked and available, which requires support sonally don’t have any obstacles now, even if I go back to the Roman Catholic [facility] where I studied, I will ed- from and coordination with Ministry of Health au- ucate them about the [PPIUD].––Provider thorities. At the time of the study, AGOTA sup- plied PPIUD equipment at no charge. Many Barriers. The most common potential barrier respondents expressed frustration with the short- to diffusion was that faith-based facilities would age of PPIUD equipment and supplies, and, as object to implementing PPIUD services. Conse- more women learned about the PPIUD Initiative, quently, both women and providers believed that equipment shortages became increasingly prob- a PPIUD intervention would only be effective and lematic. Despite an increased influx of patients, sustainable in government facilities. Another there was no equivalent increase in equipment health system-level barrier was the expectation and supplies to meet the heightened demand. for remuneration among other staff who did not Providers felt strongly that even if other govern- attend the off-site training. Providers explained ment facilities agreed to provide PPIUD services, that diffusion of information and learnings to the inconsistent provision of supplies would be other colleagues could be a challenge because problematic. This raised questions about the long- PPIUD training participants received an allow- term sustainability of the intervention without ance. Consequently, other staff may perceive this arrangement to be unfair. Despite this challenge, AGOTA support: some staff were reportedly open to learning, with- To be honest, it will be difficult to supply the instruments out expectations of rewards. This was dependent to other facilities...that is not easy, and it may take a on the workplace culture of specific facilities: long time because for now, our facility is supplied by ’ ’ There are some who received it well. At this facility, we donors. That s why it s possible. But with the govern- have a norm that if you go to a training, when you come ment, you may write a request for the material until all back you have to provide feedback. So when you’re on the ink in that pen is gone, and still not get what you –– shift and you have some time, you can instruct and teach asked for! Provider others what you learned [...] but not all staff do this be- cause some may complain, saying, “You got the money and now you come back with just words.” ––Provider Service Outcomes Equity Barriers. Equity was the main service outcome Sustainability construct to emerge from IDIs. At the health sys- Intervention sustainability is the extent to which a tem level, a key barrier to equitable PPFP counsel- newly implemented intervention is “maintained ing was differential treatment by health care or institutionalized within a service setting’s ongo- providers. One woman suggested that adolescents ing, stable operations.”27 Penetration and sustain- are reluctant to seek family planning counseling ability are conceptually similar, but temporally out of fear of judgment by health care providers. distinct, as higher penetration typically contri- In addition, some providers reportedly prioritized butes to long-term sustainability. women who attended antenatal clinics with their

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husbands, whereas those who attended alone In addition to feeling supported by health care waited longer for services: providers, several women highlighted the impor- tant role of their husbands in supporting their de- They would prioritize women who came with their cision to use PPIUD. Another motivator to use husbands. It did not matter whether you were there PPIUD was a shared intention among couples to first, they would ask those who came with their space pregnancy for financial reasons: husbands to go in for the services first [...] In most cases, my husband is always with me because he knows Depending on my business and the way I planned with when you go to the clinic with a man, you will be given my husband, I know that if I use the loop, there are some priority. ––Woman, postpartum things we will be able to accomplish before getting preg- nant again. ––Woman These reports indicate a lack of fidelity to the intervention, as providers were trained to counsel At the community level, 2 important factors all ANC clients and to tailor contraceptive method facilitated women’s receptiveness to PPFP coun- recommendations according to women’s individ- seling and PPIUD services. The first was communi- ual needs regardless of age or marital status. ty norms around preference for long birth spacing. Another barrier to equitable service delivery When asked to explain why she felt it was impor- was the cost of accessing large hospitals. One pro- tant to prevent pregnancy soon after birth, a wom- vider stated that lower income women have a ten- an described the shame and stigma associated with dency to deliver at peripheral facilities because short birth spacing: they are less busy, closer to home, and less costly ’ to access. Transportation to large hospitals for de- First, it s because the baby will still be very young, [and] livery or PPIUD services may not be feasible for second, I feel shame when I am in the community, women with fewer resources: getting pregnant when the baby is only about 4 or 5 months old; it’s a shameful thing! [...] If you happen Another challenge is women’s economic status. Some to get pregnant [again], they tend to put all the weight give birth here (at the health center) for free, but when on women, like, “how did you let yourself get preg- you ask her to take a [USD$0.86] bajaji (motorized rick- nant?” He won’t abandon you, but he will put all the shaw) to [the hospital], she can’t manage it, so we feel blame on you, saying that you did it on purpose. –– that we are going to lose them ...and the providers there Woman, prenatal (at the hospital) are overloaded, so women are scared. They prefer to get the delivery services here ...the hospi- Second, the presence of women who had tal is very busy. ––Provider positive experiences using PPIUD was a critical community-level facilitator of PPIUD counseling Lastly, although the PPIUD Initiative was and service uptake. Participants described a com- designed for implementation only at the facility munity diffusion effect in which nonusers were level, both women and providers viewed the lack encouraged by “positive deviants”––peers who of community-based PPFP counseling as a missed had opted for the PPIUD and could speak from opportunity for equitable service delivery: firsthand experience: We should also get out of this hospital and educate At some point I was acting like an ambassador for the people in the village because problems are not only in IUD because many women would come to me; they felt town. A majority who face challenges are in the villages, that I understood more. Even the health service provi- ... in our districts we have to go there and train ders would tell women to [talk to me] and I would share –– people. Provider with them what the IUD was all about. Many women questioned how the PPIUD could be inserted immediate- ly after delivery. They thought it was impossible. –– Client Outcomes Client Receptiveness and Demand for Services Woman, postpartum Although women’s receptiveness was not includ- Despite the strong influence of their peers and ed in the original implementation outcomes neighbors, women were generally receptive to framework, we consider it an important addition, biomedical information and the advice provided as factors motivating or discouraging engagement by medical professionals, and most were likely to with the intervention may directly influence both show interest in the PPIUD if providers demon- implementation and PPIUD uptake. strated their own approval of the method. Facilitators. Women identified several facili- At the policy level, the most important facilita- tators of PPIUD uptake at the partner/family level. tor of PPIUD uptake was the availability of cost-

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free insertion services. Despite Tanzania’s policy to ... The providers giving PPIUD services should be provide free health services for pregnant women trained [on insertion] and should only be allowed to and users of family planning services, some wom- provide that service when they are competent; otherwise, en were not aware that PPIUD and other contra- many women run away from using the IUD. –– ceptive methods were available free of cost. As a Woman, postpartum provider noted, informing women of this policy influenced their decision to choose the method. Barriers . We identified several important bar- DISCUSSION riers to PPIUD demand at multiple levels. Many This study applied 2 theory-based frameworks to individual-level factors influenced women’s deci- assess the implementation of a postpartum contra- sions to use PPIUD, which we have reported else- ception intervention in 5 Tanzanian hospitals. where in depth.29 These included fear of insertion, Applying a PPFP ecological framework to analyze concerns related to sexual experiences postinser- qualitative IDIs demonstrated that successful im- Successful tion, unexpected expulsion, and experience of un- plementation and uptake of PPIUD counseling implementation of anticipated side effects. and services depends on a complex interplay of PPIUD counseling factors operating at multiple levels, spanning and services Satisfaction from the individual (woman) level to the policy depends on a Facilitators . At the health system level, level. In addition, using the implementation complex interplay ’ women s PPFP counseling experience influenced outcomes framework informs our theoretical un- of factors their overall satisfaction with PPFP services. derstanding of the implementation process, illu- operating from These included the use of counseling aids during minating the “black box” of implementation the individual to prenatal counseling (leaflets, waiting room videos, dynamics, and highlights potential entry points the policy level. and brochures), and most importantly, having ac- for improvement in program delivery.27 cess to female family planning service providers. Overall, acceptability of the PPIUD Initiative Women were generally more satisfied with care was high. However, providers perceived the selec- and more motivated to use PPIUD when coun- tive training of some staff only on PPFP counsel- seled by female nurses who could speak to their ing, and others on both PPFP counseling and personal experience using family planning. PPIUD insertion to be inequitable, which may Women also appreciated providers who were re- have led to demotivation. The extent to which spectful, compassionate, and patient, indicating clinic staff are both “intrinsically” and “externally” that interpersonal aspects of care are a valued motivated, valued, and supported in their profes- component of PPFP services: sional roles directly influences program imple- 30,31 I am very grateful to them [providers] because they gave mentation. Previous research on promotion me all the support I needed. They were ready to answer of IUD uptake in LMICs found that provider en- my questions even before I started using the PPIUD, thusiasm is a critical driver of implementation suc- 18 when I had it and when I went to remove it ... They cess. As such, providing remuneration only to have really been supportive, even after removing providers participating in the off-site AGOTA- the PPIUD ... calling to ask if I was doing fine and hosted trainings may have weakened possible if I needed any assistance with family planning opportunities of diffusion to other facility staff. methods. ––Woman, postpartum AGOTA and FIGO believed the payments were justified given that some providers worked addi- Barriers . Although most providers reported tional hours to support the initiative; however, high confidence in their technical skills after train- this may have disincentivized employees who ing, some women reported contrasting percep- routinely work additional hours for other tasks.19 tions of providers’ clinical skills. Several women Further, ongoing payment is not sustainable,19 es- Both providers perceived technical incompetence as a primary pecially given that this intervention was imple- and women had contributor to adverse PPIUD outcomes, inclu- mented in a low-resource context. similar views that ding expulsion and/or improper placement, and There were many health system-level barriers the existing health warned that such negative experiences might de- to optimal implementation, including supply system ter future patients from using PPIUD: chain issues, gaps in referral between satellite infrastructure is The person that inserted the PPIUD for me did not insert clinics and tertiary/teaching hospitals, inadequate fragile and it well. She struggled very much, and it was like a trial staffing and supplies, and overworked providers. additional and error thing ...It was very painful because I had just A common narrative to emerge from both provi- demands further given birth. When I got home, the PPIUD was expelled ders and women is that the existing health system burden providers.

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infrastructure is fragile and any additional demands design, this modality has been successfully imple- place further burden on providers. Consequently, mented in LMICs for other reproductive health the potential of any facility-based PPFP interven- issues,39–42 and may be warranted, particularly in tion is limited if existing health systems shortfalls resource-constrained settings. However, several are not addressed first. These findings are consistent providers indicated that in practice, some women with previous studies in Tanzania, which report ir- were unable to attend the early morning group regularities in staffing, supplies and equipment, sessions and missed the opportunity for prenatal work overload, and communication challenges be- PPFP counseling. Additionally, some women had tween facilities as barriers to implementation of reservations about discussing PPFP in a group set- maternal and newborn care.16,30,32–34 ting due to age-related social dynamics. Given that Further, although there was high acceptance women seeking ANC are not a homogenous of the initiative, and providers repeatedly echoed group, implementation of the PPIUD Initiative the importance of PPFP on women’s health and may have been strengthened if group sessions well-being, they also perceived contraceptive were stratified by age, parity, marital status, or counseling as a time-intensive endeavor, particu- education. larly when added onto routine ANC protocols. Group- versus individual-based PPFP counsel- The perceived characteristics of an intervention ing may produce different results, and the mode of can drive the adoption process, mediating the in- counseling delivery likely influences the effective- fluence of intention to implement the program ness of PPFP programs. Research from Northern and actual behaviors to do so.35 A comprehensive Tanzania found that while PPFP counseling deliv- needs assessment to evaluate feasibility and iden- ered alongside routine prenatal HIV-testing had tify potential adaptations for the local context is an effect on postpartum contraceptive intentions, recommended. For example, an audit of satellite intentions were poor predictors of postpartum re- clinics to assess providers’ current duties, work- productive behavior.43 Taken together, results call load, and willingness to take on additional tasks for additional investigation of various integration may have helped to identify clinics with more ca- models to determine the optimal timing and mode pacity to implement new initiatives. of PPFP counseling. Implementers might consider Paradoxically, if an intervention leads to in- supplementing one-on-one PPFP counseling with creased demand for services (as providers reported group education opportunities to ease the burden for PPIUD), this may diminish the quality of care on providers. However, these groups should be provided in the long run if strategies to facilitate designed with social dynamics in mind to ensure the increased workload are not in place. Another that women feel comfortable to speak freely. study in Tanzania found that unpredictable fluxes The PPIUD Initiative intended to serve women in uptake of maternal and newborn care created of all ages and socioeconomic status, and providers challenges for service delivery and directly influ- were expected to deliver comprehensive PPFP enced the quality of care provided.16 Although counseling covering all available methods. How- streamlining health care provision by integrating ever, findings suggest that interpersonal aspects services (ANC and PPFP counseling, for example) of care varied, with some women reporting rushed is often promoted to improve health system effi- or incomplete counseling or an emphasis on the Integration of ciencies,36,37 such integration must be matched PPIUD over other methods. Further, the percep- postpartum family with proportional increases in staffing, training, tion that some providers treated older women planning services and supplies. A scoping review of integration of and/or those accompanied by their husbands with existing HIV and sexual and reproductive health services more favorably during ANC suggests that fidelity services must be similarly cautions that integration of maternal to the intended PPIUD Initiative was not uniform- matched with and reproductive health services must be judi- ly achieved. This finding aligns with a previous proportional ciously planned in relation to current health sys- study in Tanzania in which adolescent mothers tems functions.38 felt stigmatized by health care providers during increases in 44 staffing, training, Providers reportedly adapted to health system ANC due to early pregnancy and childbearing. and supplies. constraints by implementing scheduled group- Such practices may reflect widely held sociocul- based PPIUD counseling sessions for women tural norms, and/or broader efforts to encourage attending ANC clinics. Their intention was to im- male involvement in reproductive health,45 but prove efficiency and reduce the burden of addi- may lead to unintended consequences in the long tional one-on-one counseling (as intended by the run. If unmarried and adolescent women (who PPIUD Initiative). Although group-based PPFP are more likely to have unmet need for contracep- counseling was a deviation from the intervention tion) perceive differential treatment by health

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care providers, they may be discouraged from as regular evaluation and feedback, strengthened seeking future care. Women are also likely to dis- organizational culture, and an emphasis on collab- cuss these experiences with peers, and a general oration and partnership between facilities may im- mistrust of providers and/or reluctance to seek prove implementation outcomes.46 To strengthen care may diffuse among communities. Unless eq- coordination between satellite facilities and hos- uitable, high-quality care is delivered, these social pitals, we recommend a stronger interfacility diffusion dynamics will ultimately threaten the performance and quality improvement system be long-term sustainability of PPFP interventions. implemented from the outset of future initiatives. Narratives suggest that women in our study were strongly influenced by their peers. One Strengths and Limitations “ woman viewed herself as an ambassador for the This was a qualitative study with purposively se- ” IUD and took great pride in sharing her experi- lected participants; therefore our results are not ence with others. Future initiatives could consider transferrable beyond the study sample. Interview- Future initiatives engaging women with positive experiences to ing both women and providers captured a range of could engage help facilitate diffusion of information to their perspectives on implementation, service, and client women with peers, both within the community and at facilities. outcomes. However, interviews were often held at positive This may be particularly useful in facilities where the participating facility, increasing the risk of social experiences to providers are overburdened. desirability bias. To minimize this risk, interviews help facilitate ’ Although women s receptiveness to PPIUD were held in rooms with both audio and visual pri- diffusion of services was strongly influenced by the experience vacy. Given that many participants’ spoke candidly information to of their peers, the perspectives of female providers about their experiences and concerns, we believe their peers. were highly valued, primarily due to their ability social desirability bias was minimal. A further limi- to empathize with clients. This represents an im- tation is that we interviewed providers at only a portant opportunity for intervention. However, single time point. Implementation outcomes are ’ women s perceptions regarding differential treat- dynamic, and provider perspectives may change ment have concerning implications for long-term throughout the course of the initiative.27 How- sustainability. Additional training and supervision ever, implementation tends to be most difficult to improve interpersonal aspects of care, including during its early stages, and by capturing providers’ an emphasis on patient-centered counseling, in- immediate reactions and perceptions during the formed choice, and respectful and nondiscrimina- initial phase, we were able to highlight key oppor- tory service delivery should be integrated into tunities for improved implementation of future future PPFP initiatives. PPFP initiatives. Narratives suggest that it is less feasible for women of lower socioeconomic status to deliver in tertiary teaching hospitals, despite referral to CONCLUSIONS these facilities for PPIUD. Both delivery and Renewed interest in postpartum family planning PPIUD services were free of cost, but some women has ushered in a wave of interventions aimed to expressed concerns about distance, cost of trans- increase contraceptive use immediately following port, unfamiliarity with staff, and overcrowding birth, including a focus on long-acting reversible in hospitals. This suggests that the PPIUD methods. However, in LMICs such as Tanzania, Initiative may unintentionally give privilege to health systems are overburdened, and providers women with greater financial means and those often have limited resources to implement new who may be more motivated to complete the initiatives with high fidelity. Constraints that im- PPIUD referral and deliver at tertiary hospitals. pede implementation of novel PPFP programs in Although the initiative’s referral system was resource-poor contexts are often overlooked46; intended to streamline service delivery, the inter- yet, given rapid development and eagerness to vention does not address the barriers women en- adopt effective programs, implementation strate- counter when attempting to complete referrals. gies in these settings require attention. Additionally, the designated trainer at each Meeting women’s contraceptive needs is cru- teaching hospital was expected to provide cascade cial to reduce adverse maternal and infant health training and ongoing support to other staff; how- outcomes in LMICs, yet there is limited research ever, we do not have evidence to suggest that su- on the implementation of postpartum family plan- pervision strategies were implemented in the ning programs in these contexts. Continued initial months to ease adoption or facilitate sus- efforts to integrate contraceptive counseling into tainability. Improved supervision strategies such ANC as a part of national guidelines, and offering

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PPIUD insertion as part of a country’s method mix analysis. Obstet Gynecol. 2018;132(4):895–905. CrossRef. make implementation studies of such initiatives Medline increasingly important. 14. Doctor HV, Nkhana-Salimu S, Abdulsalam-Anibilowo M. Health fa- cility delivery in sub-Saharan Africa: successes, challenges, and implications for the 2030 development agenda. BMC Public Health. Acknowledgments: We are grateful to the women and health care 2018;18(1):765. CrossRef. Medline providers who shared their experiences with the research team. We acknowledge the PPIUD Tanzania research team, including Goodluck 15. Ministry of Health, Community Development, Gender, Elderly and Mbando, Angelica Rugarabamu, Caritas Pesha, and Joseph Children (MOHCDGEC) Tanzania Mainland, Ministry of Health Tumushabe, for their contributions to this research study. 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29. Huber-Krum S, Hackett K, Senderowicz L, et al. Women’s perspec- 38. Hope R, Kendall T, Langer A, Bärnighausen T. Health systems inte- tives on postpartum intrauterine devices in Tanzania. Stud Fam gration of sexual and reproductive health and HIV services in sub- Plann. 2019;50(4):317–336. CrossRef. Medline Saharan Africa: a scoping study. J Acquir Immune Defic Syndr. – 30. Manongi RN, Marchant TC, Bygbjerg IC. Improving motivation 2014;67 (Suppl 4):S259 S270. CrossRef. Medline among primary health care workers in Tanzania: a health worker 39. Lori JR, Ofosu-Darkwah H, Boyd CJ, Banerjee T, Adanu RMK. perspective. Hum Resour Health. 2006;4(1):6. CrossRef. Medline Improving health literacy through group antenatal care: a prospec- 31. Stokes T, Shaw EJ, Camosso-Stefinovic J, Imamura M, Kanguru L, tive cohort study. BMC Pregnancy Childbirth. 2017;17(1):228. Hussein J. Barriers and enablers to guideline implementation strate- CrossRef. Medline gies to improve obstetric care practice in low- and middle-income 40. Sharma J, O’Connor M, Rima Jolivet R. Group antenatal care models countries: a systematic review of qualitative evidence. Implement Sci. in low- and middle-income countries: a systematic evidence synthe- 2016;11(1):144. CrossRef. Medline sis. Reprod Health. 2018;15(1):38. CrossRef. Medline 32. Baker U, Hassan F, Hanson C, et al. Unpredictability dictates quality 41. Boyee D, Peacock E, Plotkin M, et al. What messages are adolescent of maternal and newborn care provision in rural Tanzania- a quali- voluntary medical male circumcision (VMMC) clients getting and tative study of health workers’ perspectives. BMC Pregnancy how? Findings from an observational study in Tanzania. AIDS Childbirth. 2017;17(1):55. CrossRef. Medline Behav. 2017;21(5):1383–1393. CrossRef. Medline 33. Kwesigabo G, Mwangu MA, Kakoko DC, et al. Tanzania’s health 42. Campbell C. Creating environments that support peer education: system and workforce crisis. J Public Health Policy. 2012;33 Suppl 1: experiences from HIV/AIDS-prevention in South Africa. Health S35–S44. CrossRef. Medline Education. 2004;104(4):197–200. CrossRef 34. Immediate postpartum family planning: A key component of 43. Keogh SC, Urassa M, Kumogola Y, Kalongoji S, Kimaro D, Zaba B. childbirth care. High Impact Practices in Family Planning website. Postpartum contraception in Northern Tanzania: Patterns of use, re- Published October 2017. Accessed June 10, 2019. https://www. lationship to antenatal intentions, and impact of antenatal counsel- fphighimpactpractices.org/briefs/immediate-postpartum-family- ing. Stud Fam Plann. 2015;46(4):405–422. CrossRef. Medline planning/ 44. Hackett K, Lenters L, Vandermorris A, et al. How can engagement of 35. Frambach RT, Schillewaert N. Organizational innovation adoption: adolescents in antenatal care be enhanced? Learning from the per- a multi-level framework of determinants and opportunities for future spectives of young mothers in Ghana and Tanzania. BMC Pregnancy research. J Business Res. 2002;55(2):163–176. CrossRef Childbirth. 2019;19(1):184. CrossRef. Medline 36. Firoz T, McCaw-Binns A, Filippi V, et al. A framework for healthcare 45. Peneza AK, Maluka SO. ‘Unless you come with your partner you will interventions to address maternal morbidity. Int J Gynaecol Obstet. be sent back home’: strategies used to promote male involvement in 2018;141(Suppl 1):61–68. CrossRef. Medline antenatal care in Southern Tanzania. Glob Health Action. 2018;11 37. Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn (1):1449724. CrossRef. Medline JE. Continuum of care for maternal, newborn, and child health: from 46. Yapa HM, Bärnighausen T. Implementation science in resource-poor slogan to service delivery. Lancet. 2007;370(9595):1358–1369. countries and communities. Implement Sci. 2018;13(1):154. CrossRef. Medline CrossRef. Medline

Peer Reviewed

Received: October 20, 2019; Accepted: June 2, 2020

Cite this article as: Hackett K, Huber-Krum S, Francis JM, et al. Evaluating the implementation of an intervention to improve postpartum contraception in Tanzania: a qualitative study of provider and client perspectives. Glob Health Sci Pract. 2020;8(2):270-289. https://doi.org/10.9745/GHSP-D-19- 00365

© Hackett et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https:// doi.org/10.9745/GHSP-D-19-00365

Global Health: Science and Practice 2020 | Volume 8 | Number 2 289 FIELD ACTION REPORT

Recall Efforts Successfully Increase Follow-Up for Cervical Cancer Screening Among Women With Human Papillomavirus in Honduras

Kerry A. Thomson,a Manuel Sandoval,b Carolyn Bain,a Francesca Holme,a Pooja Bansil,a Jacqueline Figueroa,c Silvia de Sanjoséa

Key Findings ABSTRACT Scaling up coverage of routine cervical screening in low-resource set- n For most women at high risk of cervical tings must be accompanied by efforts to retain women throughout the precancer, a reminder phone call on the screening cascade and continuum of care, including adequate follow- importance of rescreening for cervical cancer was up of abnormal results. The Scale-Up Project implemented human papillomavirus (HPV) testing for cervical cancer screening within sufficient to prompt women to return to the clinic public-sector health facilities in Honduras between 2015 and 2019. for rescreening 1 year later. Women who were HPV-positive but did not have visually confirmed n Women who needed to be contacted 3 or more cervical lesions upon visual inspection with acetic acid (VIA-negative) times were significantly less likely to return to the were instructed to return to the health center after 1 year for repeat clinic, suggesting that there will be diminishing HPV testing. The current evaluation assessed the effectiveness of recall returns to protracted tracing efforts per woman. strategies to prompt women to return for retesting. Clinic staff placed reminder phone calls and followed up with short message service (SMS) or home visits, if needed. We summarized number of contacts, Key Implications type of contacts, and time elapsed until return to the clinic, and used log-binomial regression to identify factors associated with return to n Cervical cancer screening is only effective when the clinic. We identified 558 women who were initially HPV-positive women with positive screening results are VIA-negative from 8 clinics as needing repeat HPV testing 1 year lat- linked to treatment. Programs need to invest er. Mean age was 43.2 years. Nearly all women (98.6%) were suc- effort in robust follow-up systems for women cessfully contacted and 75.1% completed repeat HPV testing. The with abnormal results at any step of the cervical majority of contacts (65.4%) were phone calls, and nearly half of women who returned to the clinic (42.9%) did so after 1 contact. cancer screening and treatment cascade. Mean days between contact and presentation at the clinic was n Program planners should build in reminder and 10.7 (standard deviation: 14.7). Women who required 3 or more recall strategies as part of a successful cervical contacts were 21% less likely to return for repeat HPV testing (preva- cancer screening program. lence ratio: 0.79; 95% confidence interval=0.69,0.90; P<.001) as compared to women who received only 1 contact. Reminder phone calls were highly successful at recalling women for HPV retesting in Honduras. This low-touch intervention should be included as part of standard follow-up to retain women throughout the continuum of cer- vical cancer screening and treatment. BACKGROUND ervical cancer is the fourth most common cancer accompanied by ambitious targets for secondary preven- Caffecting women worldwide, and an estimated tion, including screening 70% of women at 35 years and 90% of deaths from cervical cancer occur in low- and 45 years of age with a high-precision screening test and middle-income countries (LMICs), highlighting the con- treatment for 90% of women with detected cervical tinued need for effective screening and treatment pro- lesions.2 Scaling up coverage of routine cervical screen- 1 grams in these settings. The 2018 call for elimination ing in LMICs must be accompanied by efforts to retain of cervical cancer by World Health Organization (WHO) women throughout the screening cascade and continu- Director-General Dr. Tedros Adhanom Ghebreyesus is um of care, including adequate follow-up of abnormal results and linkage to treatment. a PATH, Sexual & Reproductive Health Program, Seattle, USA. b Asociación Hondureña de Planificación de Familia, Tegucigalpa, Honduras. Current WHO guidelines in settings with sufficient c Secretary of Health, Tegucigalpa, Honduras. resources to implement human papillomavirus (HPV) Correspondence to Silvia de Sanjosé ([email protected]). testing include the option of following a primary HPV

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test with triage using visual inspection with acetic Salvador, Guatemala, Honduras, and Nicaragua acid (VIA), treating women who both test positive between 2014 and 2019. Project details have been for HPV and have visually confirmed cervical described previously.8,9 In brief, in Honduras, lesions, and repeating screening after 1 year for PATH partnered with the Ministry of Health and a women who tested positive for HPV but do not local nongovernmental organization, Honduras have visible lesions.3 Rescreening women who Association of Family Planning (ASHONPLAFA), are HPV-positive VIA-negative helps to address to introduce HPV testing using careHPV (QIAGEN, limitations in the combined sensitivity of HPV test- Hilden, Germany), a signal-amplification batch di- ing and VIA screening and offers a second oppor- agnostic test for high-risk HPV DNA detection. A tunity to identify persistent HPV infections that total of 44,314 women were tested for HPV across 4 are more likely to result in cervical precancer, 3 departments (Copán, El Paraíso, and Region while reducing potentially unnecessary treatment. Metropolitana de Francisco Morazán, which The majority of women will clear their HPV infec- 8 5 includes the capitol city of Tegucigalpa). tion within 1 to 2 years. How-ever, women with Following WHO 2013 recommendations3 and persistent infection are at high risk for developing 2015 Honduras guidelines10 for cervical cancer cervical lesions and warrant ongoing monitoring 4 screening and treatment, women who tested pos- and/or treatment, especially in settings where a itive for HPV were triaged using VIA to confirm woman may only have 1 or 2 opportunities for pri- the presence of lesions. Women who were HPV- mary screening in her lifetime. positive VIA-positive were considered positive for A challenge of multi-step screening algorithms cervical precancer and recommended for ablative is opportunity for delays and loss to follow-up treatment, if eligible, or more advanced treatment in between screening steps, especially when sig- if needed. Women who were HPV-positive VIA- nificant time elapses between contacts. In the negative were considered negative for cervical Jujuy Demonstration Project in Argentina, wom- en 30 years of age and older were first tested for precancer but counselled on the potential implica- HPV; women who tested positive for HPV under- tions of persistent infection and instructed to re- went cytology. Of the 49,565 women tested, turn to the health center in approximately 1 year 67% were HPV-positive and had negative cytolo- for repeat HPV testing (Figure 1). Initially, the gy; 70.1% of these women completed a repeat Honduran health system did not actively track at- HPV test, although only 26% completed the retest tendance at 1-year return visits for HPV-positive within the recommended 12-18 month time- VIA-negative women; it was each individual frame.6 Documented loss to follow-up from cervi- woman’s responsibility to return for screening af- cal cancer screening programs in low-resource ter 1 year. After anecdotal observation that very settings is as high as 70%, although studies have few women were returning for this follow-up mainly focused on attrition of women diagnosed visit, the current evaluation was designed to with cervical precancer for whom treatment assess the success of various recall strategies to status is not known.7 There has been less focus encourage women who were HPV-positive VIA- on retention of screen-positive women who do negative to return for follow-up ≥ 1 year after their not yet need treatment but do need continued sur- initial screening result. veillance for persistent HPV infection and devel- opment of cervical precancer. This subgroup of women, often overlooked in both program plan- IMPLEMENTATION OF RECALL ning and reporting, are likely to increase in size STRATEGIES TO IMPROVE as more countries adopt multistep screening FOLLOW-UP algorithms. Women who were HPV-positive VIA-negative as Our objective was to evaluate the success of re- part of the Scale-Up project after 2017 and had call strategies to encourage women to return for not yet spontaneously presented to the clinic for ≥ follow-up 1 year after receiving HPV-positive follow-up within 15 months of their initial screen- VIA-negative screening results in public-sector ing date were traced between October 2018 and health clinics in Honduras. March 2019. For each family that receives care from public health clinics, a household health re- INTRODUCTION OF HPV TESTING cord is maintained, including demographics, con- FOR CERVICAL CANCER SCREENING tact information, dates of screening, and testing The current evaluation was nested within the outcomes. Individual health visits (and dates) are Scale-Up Project which was implemented in El recorded in a paper-based registry. In parallel,

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FIGURE 1. Cervical Cancer Screening Algorithm Followed in the Scale-Up Project, Honduras

Primary screening with HPV

HPV Negave HPV Posive

Repeat HPV VIA test in 5 years

VIA posive VIA negave

Linked to Repeat HPV treatment test in 1 yeara

Abbreviations: HPV, human papillomavirus; VIA, visual inspection with acetic acid. a The current evaluation focuses on HPV-positive, VIA-negative women due for repeat HPV testing at 1 year.

ASHONPLAFA maintained a Microsoft Excel reg- outreach. The evaluation protocol was reviewed istry of all HPV-positive VIA-negative women. by PATH Research Determination Committee and The list of women’s names was provided to each was categorized as nonresearch. Data analysis was clinic, where staff verified a woman’s initial conducted using Stata (version 13.1, College screening result and date in the clinic-based paper Station, TX).11 register. As the first and primary outreach activity, staff attempted to contact each woman by phone. KEY FINDINGS When successful contact was made, clinic staff We included a total of 558 women who were reminded women of the need for HPV retesting HPV-positive VIA-negative and needed rescreen- and invited them to return to the clinic for a ing ≥1 year. Mean age among all women was follow-up HPV test. If women could not be 43.2 years (standard deviation [SD]: 9.6). Most reached for conversation via phone, staff would women for whom age was available (70.8%) were attempt to send a SMS or conduct a home visit. If between 30 and 50 years of age. Among women for a woman still could not be reached, staff would at- whom parity was recorded, the majority (78.7%) of tempt to call the alternate contact listed in the womenhad2ormorechildren(Table 1). woman’s health record. Deidentified individual A total of 419 women returned to the clinic for level data on the number and type(s) of contact retesting, of which 20 women (3.6%) presented to and whether women completed retesting were the clinic spontaneously for retesting before being recorded on paper forms and later entered into recalled by clinical staff and 399 (71.3%) required Excel. When women presented to the clinic for at least 1 contact before returning for retesting retesting, they were asked to report which recall (Figure 2). Nearly half of women (45.1%) returned method prompted them to return to the clinic. to the clinic after 1 contact, of whom the majority The algorithm for rescreening was consistent received 1 phone call (94.4%) and a small number with that of the initial screening described above of women received a home visit before a phone call (Figure 1). Data on HPV test results, triage, and (5.6%) because clinic staff were already in their treatment outcomes were recorded in aggregate neighborhood conducting other outreach activi- form at each clinic for women who had received ties. Slightly more than half of the women

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(54.9%) required more than 1 contact before pre- contacted 1 or more times and did not report a spe- senting to the clinic for retesting; the majority of cific reason for declining rescreening but also did these women received phone calls only (89.0%) not return to the health clinic before the end of while a small proportion required a combination the evaluation period (Table 2). A small propor- of phone call(s) followed by a home visit (7.3%) tion of women could not be contacted (1.4%), or phone call(s) followed by SMS (3.7%). had moved (6.5%), reported barriers to clinic at- The maximum number of contact attempts for tendance (2.2%), cited pregnancy status as a rea- any woman was 8, and mean number of contacts son for not wanting rescreening (1.4%), or received by women who returned to the clinic was reported refusal to return to the clinic (2.9%). 2.1 (SD: 1.5, Table 2). The average length of time Eighteen percent of women reported that they Nearly 87% of elapsed between first contacting a woman and had already been rescreened (and if needed, trea- women reported presenting to the clinic was 10.7 days. The majori- ted) at a different health facility. that the clinic ty of women (86.6%) reported that a phone Table 3 presents differences between women staff’s phone call call from clinic staff was the motivator that who did and did not return to the clinic for rescre- motivated them to prompted them to return to the clinic and com- ening. Women who required 3 or more contacts return to the clinic plete rescreening. were 21% less likely to return for rescreening for rescreening. Nearly one-quarter of women (24.9%) did (prevalence ratio [PR]: 0.79; 95% confidence in- not return for rescreening (Figure 2). The majority terval [CI]=0.69,0.90; P<.001) as compared to of these women (67.6%) were successfully women who received only 1 contact. Women

TABLE 1. Demographic Characteristics of Women Who Were HPV-Positive VIA-Negative and Indicated for HPV Retesting After 1 Year, Honduras

Characteristics All women, No. (%) 558 (100) Clinic Location Carrizal, No. (%) 77 (13.8) Las Crucitas, No. (%) 48 (8.6) San Benito, No. (%) 33 (5.9) San Miguel, No. (%) 98 (17.6) Alonzo Suazo, No. (%) 110 (19.7) Villadela, No. (%) 59 (10.6) Monterey, No. (%) 77 (13.8) Pedregal, No. (%) 56 (10.0) Parity No children, No. (%) 4 (0.7) 1 child, No. (%) 22 (3.9) 2 or more children , No. (%) 96 (17.2) Not documented, No. (%) 436 (78.1) Age Category, years < 30, No. (%) 4 (0.7) 30–39, No. (%) 162 (29.0) 40–49, No. (%) 122 (21.9) 50–59, No. (%) 90 (16.1) ≥ 60, No. (%) 23 (4.1) Not documented, No. (%) 157 (28.1) Age, mean (standard deviation) 43.2 (9.6)

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FIGURE 2. Overview of Recall Efforts to Encourage HPV-Positive VIA-Negative Women to Return for Clinic- Based HPV Testing ≥1 Year After Their First HPV-Positive Test Result

HPV posive/VIA negave and in need of rescreening aer 1 year N=558

Required ≥ 2 contacts to return to clinic Returned to clinic Required 1 contact to return to clinic n=219 (39.3%) spontaneously n=180 (32.3%) > 1 phone call n=195 (89.0%) n= 20 (3.6%) Phone only n=170 (94.4%) > 1 phone call and home visit n=16 (7.3%) Home visit only n=10 (5.6%) > 1 phone call and SMS n=8 (3.7%)

Returned to clinic and Did not return to clinic completed HPV retesng n=139 (24.9%) n=419 (75.1%)

Abbreviations: HPV, human papillomavirus; VIA, visual inspection with acetic acid.

with 2 or more children were 9% less likely to re- clinic, suggesting that there will be diminishing turn to the clinic (PR: 0.91; 95% CI=0.85,0.97; returns to protracted tracing efforts per woman. P=.003) as compared to women who reported These results underscore the value of building in no children. There were some statistically signifi- recall strategies as part of a successful cervical can- cant differences in the success of recall efforts cer screening program and demonstrate that a across clinic sites; women from San Miguel, Villa simple recall phone call can have a big impact on Adela, Monterey, and Pedregal clinic sites were retention. 30% more likely to complete screening as com- Although screening approaches will continue pared to women in Carrizal (Table 3). to vary widely across settings, it is critical for pro- grams to invest effort in robust follow-up systems IMPLICATIONS FOR CERVICAL for women with abnormal results at any step of the cervical cancer screening cascade.4 Monitor- CANCER SCREENING PROGRAMS ing and retaining women throughout the Our study describes the substantial impact that continuum of cervical cancer screening is a key simple recall efforts, primarily phone calls, had component to reduce morbidity and mortality as- on encouraging women to complete follow-up sociated with cervical cancer. Earlier work to as- for cervical cancer surveillance and successfully sess the cost-effectiveness of various screening engaging them in rescreening. Although the approaches in Latin American has demonstrated Tegucigalpa population is slightly mobile, most the importance of adequate follow-up of abnor- ≥ 16 women could be contacted 1 year after their ini- mal screening. A mathematical model based on tial screening visit. In the majority of cases, phone various screening scenarios in Colombia estimated calls alone were sufficient to recall women, nearly that 50% coverage with 100% follow-up reduced half of the women who returned to the clinic did cervical cancer mortality by 21.3% more than a so after 1 contact, and most women returned scenario with 100% coverage and 50% follow-up.17 These results within 2 weeks of being contacted. These findings Although we did not document the HPV underscore the suggest that for most women a reminder on the test result for all women who were traced and value of building importance of rescreening was sufficient to over- returned to the clinic for retesting, registry data in recall strategies come any potential barriers to clinic attendance from the 8 clinics serving the same patient popula- as part of a and adherence to follow-up appointments that tion indicate that among a sample of 298 women – successful cervical are commonly reported in the literature.12 15 who initially were HPV-positive VIA-negative, cancer screening Women who needed to be contacted 3 or more 36% tested positive for HPV ≥ 1 year later. program. times were significantly less likely to return to the This evidence confirms the need for continued

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TABLE 2. Recall Methods Used To Encourage Repeat HPV Testing Among Women With Initial HPV-Positive VIA-Negative Screening Results, Honduras

Total N = 558

Contacts received per woman, mean (SD) [range] 2.3 (1.5) [1–8] Contacts received per woman who returned for 1-year follow-up (n=419a), mean (SD) [range] 2.1 (1.5) [0–8] Phone calls/voicemails placed per woman, No. (%) 1 211 (42.5) 2 118 (23.8) 3 86 (17.3) 4 or more 76 (15.3) Missing 5 (1.0) Days between first outreach and returning for 1-year follow-up (n=344b) , mean (SD) [range] 10.7 (14.7) [0–104) Self-reported recall method that motivated clinic attendance (n=419) , No. (%) Telephone contact (phone call or text/SMS) 364 (86.9) Home visit 25 (6.0) None (presented spontaneously) 19 (4.5) Voicemail 2 (0.5) Not documented 9 (2.1) Self-reported reasons for not returning for 1-year follow-up (n=139), No. (%) No reason specified 94 (67.6) Repeat testing and follow-up happened at another clinic 25 (18.0) Moved away from clinic area 9 (6.5) Successfully contacted and declined 4 (2.9) Cannot come due to work or personal reasons 3 (2.2) Could not contact or locate 2 (1.4) Pregnant 2 (1.4)

Abbreviations: HPV, human papillomavirus; VIA, visual inspection with acetic acid; SD, standard deviation. a Denominator excludes women who did not return to the clinic. b Denominator excludes women with missing information.

surveillance of this subgroup over time. Among a women who are HPV-positive without a triage cohort of Dutch women who were HPV-positive step. A recent study in Papua New Guinea using and had negative cytology, 56.6% were HPV- cytology as the reference standard concluded that positive when retested an average of 10 months treating all women who are HPV-positive resulted 18 later. Women who test positive on 2 consecutive in appropriate treatment of 92% of women with HPV tests may be candidates for treatment, espe- high-grade disease and 13% overtreatment, as cially in low-resource settings where engagement compared to a combined algorithm of HPV testing with the health system may be limited. Another option that takes into consideration high rates followed by VIA for triage which resulted in 45.5% 19 of persistent HPV infection and the challenges appropriate treatment and 3.7% overtreatment. El recalling women for retesting is a “test-and-treat” Salvador has adopted this approach; all women who approach, wherein treatment is offered to all are HPV-positive receive VIA to confirm eligibility for

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TABLE 3. Factors Associated With Completion of HPV Retesting Among Women With Initial HPV-Positive VIA-Negative Screening Results, Honduras, N=544a

Did Not Return to Clinic Returned to Clinic for HPV Retesting n=139 n=415 No. (%) [95%CI] No. (%) [95%CI] Prevalence Ratio (95% CI) P Value

Number of contactsb 1 contact 46 (20.4) [15.6,26.1] 180 (79.7) [73.9,84.4] Ref — 2 contacts 22 (18.6) [12.6,26.8] 96 (81.4) [73.2,87.4] 1.02 (0.92,1.14) .70 ≥ 3 contacts 71 (37.2) [30.6,44.3] 120 (62.8) [55.7,69.4] 0.79 (0.69,0.90) <.001 Parity No children 0 (0) 4 (100.0) Ref — 1 child 2 (9.5) [2.3,32.0] 19 (90.5) [68.0,97.7] 0.91 (0.79,1.04) .16 2 or more children 9 (9.6) [5.0,17.5] 85 (90.4) [82.5,95.0] 0.91 (0.85,0.97) .003 Not documented 128 (29.4) [25.3,33.9] 307 (70.6) [66.1,74.7] — Clinic Carrizal 26 (33.8) [24.0,45.1] 51 (66.2) [54.9,76.0] Ref — Las Crucitas 25 (52.1) [38.0,65.9] 23 (47.9) [34.1,62.0] 0.72 (0.52,1.01) .06 San Benito 6 (18.8) [8.5,36.3] 26 (81.2) [63.7,91.5] 1.22 (0.97,1.55) .08 San Miguel 14 (14.3) [8.6,22.8] 84 (85.7) [77.2,91.4] 1.29 (1.08,1.54) .005 Alonzo Suazo 41 (37.3) [28.7,46.7] 69 (62.7) [53.3,71.3] 0.95 (0.76,1.17) .62 Villadela 7 (12.1) [5.8,23.4] 51 (87.9) [76.6,94.2] 1.32 (1.10,1.60) .003 Monterey 11 (14.7) [8.3,24.7] 64 (85.3) [75.3,91.7] 1.29 (1.08,1.55) .007 Pedregal 9 (16.1) [8.5,28.3] 47 (83.9) [71.7,91.5] 1.27 (1.04,1.54) .02 Age category, years 30–39 12 (7.4) [4.2,12.6] 150 (92.6) [87.4,95.8] Ref — 40–49 6 (4.9) [2.2,10.6] 116 (95.1) [89.4,97.8] 1.03 (0.97,1.09) .38 50–59 9 (10.0) [5.3,18.2] 81 (90.0) [81.8,94.7] 0.97 (0.90,1.05) .50 >60 2 (8.7) [2.1,29.6] 21 (91.3) [70.4,97.9] 0.99 (0.86,1.13) .84 Not documented 110 (70.1) [62.4,76.7] 47 (29.9) [23.3,37.6] ——

Abbreviations: CI, confidence interval; HPV, human papillomavirus; VIA, visual inspection with acetic acid. a Excludes women < 30 years of age (n=4). b Excludes women who returned spontaneously (n=20).

cryotherapy, but treatment is not conditional on visu- screening in South Africa found that tracing activ- al confirmation of lesions.20 ities reduced 12- and 24-month loss to follow-up This intervention required only moderate ap- by nearly 30% and successfully engaging a wom- This intervention propriation of staff time and use of clinic phones, an for follow-up at 24 months was twice as expen- required only but we did not track detailed costs associated with sive as at 12 months. However, at the time the moderate adding recall efforts to the cervical cancer screen- previous study was conducted (2005), this target appropriation of ing approach in Honduras. ASHONPLAFA and population did not have high mobile phone own- staff time and use Ministry of Health personnel championed the ership, thus requiring community health workers to make more resource-intensive home visits of clinic phones. intervention and emphasized the importance of recalling women and encouraged persistent compared to the clinic-based efforts described tracing. A costing study of cervical cancer here.7

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Our evaluation has demonstrated that the ad- delivered at scale as part of a national screening dition of a low-touch intervention in Honduras program. In health systems where specific ap- captured 75% of women indicated for retesting. pointment dates are set, reminder phone calls Phone calls were successful and sufficient to reach placed in advance of a target date can also be the majority of women, even in a setting where considered. mobile phone numbers frequently change. Few women required follow-up through alternative CONCLUSION methods including SMS. Although a manual pro- Surveillance and follow-up of abnormal screening cess of individual phone calls was successful in the results is paramount to the success of an effective context of this particular project, it is important to cervical cancer screening program. As countries consider alternate and more automated commu- scale up screening and treatment efforts, a re- nication channels when replicating and possibly minder and recall system, such as the low-touch scaling up a similar intervention to reach a larger phone reminders described here, should be in- number of women. Health information systems cluded as part of a comprehensive cervical cancer such as the open source District Health Infor- control strategy. mation Software 2 (DHIS2) or canSCREEN devel- oped by the Australian VCS Foundation specific to Acknowledgments: We extend our gratitude to Doris Rodriguez, Linda cancer surveillance have the option to flag patients Fonseca, and Jose Saul Lobo for their contributions to data collection and who are overdue for screening and auto-generate project administration. We thank the Secretary of Health of Honduras and frontline health care personnel who carried out tracing, follow-up, recall reminders by SMS or phone call. and treatment activities.

Funding: This work was supported by the Bill & Melinda Gates Limitations Foundation (Grant number OPP1086544). The findings and Women residing in the urban and periurban areas conclusions contained within are those of the authors and do not included in our evaluation live in close proximity necessarily reflect positions or policies of the Foundation. to the health facilities that contacted them. Competing interests: None declared. However, women’s ability to access services may still be encumbered by the security situation and community violence in Honduras. Thus, our REFERENCES 1. Cervical cancer. World Health Organization website. Accessed results may have limited generalizability to wom- November 18, 2019. https://www.who.int/cancer/prevention/ en residing in other settings, such as rural areas, diagnosis-screening/cervical-cancer/en/ where access barriers are likely different. 2. World Health Organization (WHO). Draft: Global strategy towards The current evaluation did not include a com- eliminating cervical cancer as a public health problem. Accessed parison group, although less than 4% of the wom- April 2, 2020. https://www.who.int/activities/a-global-strategy- en included in our screening population returned for-elimination-of-cervical-cancer to the clinic for retesting on their own before re- 3. World Health Organization (WHO). WHO Guidelines for Screening and Treatment of Precancerous Lesions for Cervical Cancer ceiving a reminder from clinic staff, suggesting Prevention. Geneva: WHO; 2013. Accessed August 13, 2019. that a large number of women would not have ini- http://www.ncbi.nlm.nih.gov/books/NBK195239/ tiated retesting in the absence of recall efforts. 4. Cuschieri K, Ronco G, Lorincz A, et al. Eurogin roadmap 2017: Literature on the impact of reminder and recall Triage strategies for the management of HPV-positive women in cer- – strategies for cervical cancer screening from vical screening programs. Int J Cancer. 2018;143(4):735 745. CrossRef. Medline LMICs is limited. An evaluation of an automated 5. Castle PE, Rodríguez AC, Burk RD, et al. Long-term persistence of reminder system integrated into the national prevalently detected human papillomavirus infections in the absence health information system in Denmark found of detectable cervical precancer and cancer. J Infect Dis. 2011;203 that prompting general practitioners to remind (6):814–822. CrossRef. Medline their female patients to return for 12-month 6. Gago J, Paolino M, Arrossi S. Factors associated with low þ follow-up of abnormal cytology reduced loss to adherence to cervical cancer follow-up retest among HPV /cytology 21 negative women: a study in programmatic context in a low-income follow-up by 48%. In low-resource settings that population in Argentina. BMC Cancer. 2019;19(1):367. CrossRef. do not yet have robust digital health information Medline systems, mobile health interventions, including 7. Goldhaber-Fiebert JD, Denny LE, De Souza M, Wright TC, Kuhn L, 1- or 2-way texting platforms22 and apps, are cur- Goldie SJ. The costs of reducing loss to follow-up in South African rently under evaluation for retaining women in cervical cancer screening. Cost Eff Resour Alloc. 2005;3:11. CrossRef. Medline the cervical cancer cascade and may offer a more 8. Holme F, Kapambwe S, Nessa A, Basu P, Murillo R, Jeronimo J. efficient, systematic, and cost-effective approach Scaling up proven innovative cervical cancer screening strategies: than individualized phone calls, especially when challenges and opportunities in implementation at the population

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level in low- and lower-middle-income countries. Int J Gynaecol 17. Andrés-Gamboa O, Chicaíza L, García-Molina M, et al. Cost-effec- Obstet. 2017;138 Suppl 1:63–68. CrossRef. Medline tiveness of conventional cytology and HPV DNA testing for cervical 9. Holme F, Jeronimo J, Maldonado F, et al. Introduction of HPV testing cancer screening in Colombia. Salud Publica Mex. 2008;50 – for cervical cancer screening in Central America: the Scale-Up proj- (4):276 285. CrossRef. Medline ect. Prev Med. 2020;106076. CrossRef. Medline 18. Polman NJ, Veldhuijzen NJ, Heideman DAM, Snijders PJF, 10. Gobierno de la Republica de Honduras, Secretaria de Salud. Meijer CJLM, Berkhof J. HPV-positive women with normal Protocolo Para el Tamizaje y Tratamiento de Lesiones Premalignas cytology remain at increased risk of CIN3 after a negative repeat – Para la Prevencion del Cancer Cervicouterino. November 2015. HPV test. Br J Cancer. 2017;117(10):1557 1561. CrossRef. Medline 11. STATA [computer program]. Version 13.1. College Station, TX: StataCorp; 2019. 19. Toliman PJ, Kaldor JM, Badman SG, et al. Performance of clinical screening algorithms comprising point-of-care HPV-DNA 12. Chidyaonga-Maseko F, Chirwa ML, Muula AS. Underutilization of testing using self-collected vaginal specimens, and visual cervical cancer prevention services in low and middle income coun- inspection of the cervix with acetic acid, for the detection of tries: a review of contributing factors. Pan Afr Med J. 2015;21:231. underlying high-grade squamous intraepithelial lesions in CrossRef. Medline Papua New Guinea. Papillomavirus Res. 2018;6:70–76. CrossRef. 13. Lim JNW, Ojo AA. Barriers to utilisation of cervical cancer screening Medline in Sub Sahara Africa: a systematic review. Eur J Cancer Care (Engl). 20. Maza M, Alfaro K, Garai J, et al. Cervical cancer prevention in El 2017;26(1). CrossRef. Medline Salvador (CAPE)-An HPV testing-based demonstration project: 14. Chorley AJ, Marlow LAV, Forster AS, Haddrell JB, Waller J. Experiences changing the secondary prevention paradigm in a lower middle- of cervical screening and barriers to participation in the context of an income country. Gynecol Oncol Rep. 2017;20:58–61. CrossRef. organised programme: a systematic review and thematic synthesis. Medline – Psychooncology. 2017;26(2):161 172. CrossRef. Medline 21. Kristiansen BK, Andersen B, Bro F, Svanholm H, Vedsted P. Impact of 15. Garrett JJ, Barrington C. ‘We do the impossible’: women overcoming GP reminders on follow-up of abnormal cervical cytology: a before- barriers to cervical cancer screening in rural Honduras–a positive after study in Danish general practice. Br J Gen Pract. 2017;67(661): deviance analysis. Cult Health Sex. 2013;15(6):637–651. CrossRef. e580–e587. CrossRef. Medline Medline 22. Momany MC, Martinez-Gutierrez J, Soto M, et al. Development of 16. Murillo R, Almonte M, Pereira A, et al. Cervical cancer screening mobile technologies for the prevention of cervical cancer in Santiago, programs in Latin America and the Caribbean. Vaccine. 2008;26 Chile study protocol: a randomized controlled trial. BMC Cancer. Suppl 11:L37–L48. CrossRef. Medline 2017;17(1):847. CrossRef. Medline

En español

Alto seguimiento de mujeres VPH positivas en el tamizado de cáncer de cuello uterino en Honduras tras contacto recordatorio

Principales Conclusiones

Para la mayoría de las mujeres a alto riesgo de lesiones precancerosas del cuello uterino, un recordatorio telefónico sobre la importancia de la visita de seguimiento fue suficiente para una alta asistencia al año de la primera visita.

El retorno en visitas de seguimiento fue muy inferior en las mujeres que necesitaron más de tres contactos telefónicos podría cuestionar la viabilidad de esfuerzos adicionales en la captación de mujeres reticentes.

Principales Implicaciones

El tamizaje cervical solo es efectivo si se aborda adecuadamente el manejo de las mujeres con resultados anormales del tamizaje. Es necesario que los programas de tamizaje dispongan de un sistema de seguimiento robusto para conseguir un adecuado seguimiento en toda la cascada de eventos que se origina en el tamizaje y tratamiento.

Los programas de tamizaje deben de incluir recordatorios y estrategias de captación de las visitas de seguimiento para conseguir que los programas de tamizaje sean exitosos.

RESUMEN

Parar retener a las mujeres que participan en programas de tamizaje del cáncer de cuello uterino en países de bajos recursos económicos es necesario considerar esfuerzos que garantizen la continuidad de la atención que incluya un adecuado seguimiento de resultados anormales. El Proyecto Scale- Up implementó la prueba del virus del papiloma humano (VPH) para el tamizaje del cáncer de cuello uterino en las instalaciones de salud del sector público en Honduras entre 2015 y 2019. Las mujeres que eran positivas para el VPH pero no tenían lesiones cervicales confirmadas visualmente reci- bieron instrucciones de regresar al centro de salud después de 1año para repetir la prueba de VPH. La evaluación actual evaluó la efectividad de las estrategias de recuerdo para hacer que las mujeres regresen para volver a realizar la prueba. El personal de las clínicas participantes realizo llamadas telefónicas recordatorias y seguimiento con SMS. En casos necesario se realizaron visitas a domicilio. Resumimos el número de contactos, el tipo de contactos y el tiempo transcurrido hasta el regreso a la clínica, y utilizamos la regresión log-binomial para identificar los factores asociados con el regreso a la clínica. Inicialmente, se identificaron 558 mujeres con una prueba VPH positiva pero que habían resultado tener prueba concomitante de IVAA negativa y que según recomendaciones, necesitaban repetir la prueba de VPH después de 1 año. La edad promedio fue de 43.2 años. La mayoría de las mujeres (98.6%) fueron contactadas con éxito y el 75.1% fueron sometidas a una prueba de seguimiento de VPH. La mayoría de los contactos (65.4%) se realizaron a través de llamadas telefónicas y casi la mitad de las mujeres que regresaron a la clínica (42.9%) lo hicieron después de un primer contacto. La media de días entre el contacto y la presentación en la clínica fue de 10.7 (desviación estandard: 14.7). Las mujeres que requirieron tres o más intentos de contacto tenían un 21% menos de probabilidades de regresar para repetir la prueba del VPH (ratio de prevalencia: 0.79; intervalo de confianza del 95%=0.69,0.90, P<.001) en comparación con las mujeres que recibieron un solo contacto. Se concluye que en Honduras las llamadas telefónicas recordatorias fueron muy satisfactorias para realizar un seguimiento adecuado y re-analizar a las mujeres para

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un posible persistencia del VPH. Se recomienda la introducción de esta intervención sencilla y de bajo coste como parte del seguimiento estandarizado para retener a las mujeres durante la cascada de detección, manejo y tratamiento del cáncer de cuello uterino.

Peer Reviewed

Received: November 19, 2019; Accepted: March 17, 2020; First published online: May 8, 2020

Cite this article as: Thomson KA, Sandoval M, Bain C, et al. Recall efforts successfully increase follow-up for cervical cancer screening among women with human papillomavirus in Honduras. Glob Health Sci Pract. 2020;8(2):290-299. https://doi.org/10.9745/GHSP-D-19-00404

© Thomson et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https:// doi.org/10.9745/GHSP-D-19-00404

Global Health: Science and Practice 2020 | Volume 8 | Number 2 299 REVIEW

Close to Home: Evidence on the Impact of Community-Based Girl Groups

Miriam Temin,a Craig J. Hecka

Key Findings ABSTRACT Purpose: Community-based programming to promote gender equi- n Evaluations of community-based girl groups ty, often delivered through community-based girl groups (CBGGs, (CBGGs) programs—sometimes called safe sometimes called “safe spaces”), is increasing. However, evidence spaces—reported positive effects on girl-level is weak on how CBGGs are implemented and their effect on adoles- outcomes that are independent of external factors cent girls’ health and well-being. We conducted a comprehensive and suboptimal performance on health behavior literature review to identify relevant CBGG programs. and health status. Methods: The review included programs with impact evaluations that used experimental or quasi-experimental design, data from n The limited evidence available shows that 2 time points, control/comparison groups, and quantitative pro- CBGGs have the potential to contribute to gram effects and P values. adolescent girls’ empowerment; complementary Results: We analyzed evaluations of 30 programs (14 random- activities are needed to mitigate risk. ized controlled trials, 16 quasi-experimental). Although program designs varied, most programs targeted unmarried girls aged 13 to 18 years who were both in school and not in school, and Key Implications who met weekly in groups of 15 to 25 girls. Nearly all programs used multisectoral approaches focusing on life skills and often economic and financial content, such as financial literacy and n Program implementers should consider the role of microsavings. Complementary activities with community mem- female mentor-led girl groups in improving bers, boys, and health services were common. Across programs, adolescent girls’ attitudes, beliefs, knowledge, evaluations reported statistically significant effects (P<.05) the and awareness on health and gender. majority (>50%) of times they measured outcomes related to gen- n Policy makers and funders should recognize that der and health attitudes and knowledge, education, psychosocial to change behaviors and sustainably reduce risk, well-being, and economic and financial outcomes. Measures of CBGGs should be combined with action to outcomes related to girls’ health behaviors and health status had engage girls’ social environments and structures. majority null findings. Conclusions: CBGG program evaluations found positive effects n Researchers should conduct rigorous on girl-level outcomes that are independent of external factors, implementation science and impact evaluation like gender norm attitudes, and suboptimal performance on studies of CBGGs to learn more about effective health behavior and health status, which rely on other people practices and the likely impact of CBGGs for and systems. This delivery model has promise for building girls’ vulnerable subpopulations of adolescent girls. assets. Complementary actions to engage girls’ social environ- ments and structures are needed to change behaviors and health status.

and middle-income countries (LMICs) has increased INTRODUCTION 2,3 overnments in countries that have populations of dramatically, hundreds of millions of adolescent girls Gmedian age under 251 face demographic pressure still lack access to essential services and basic human rights. Despite progress, globally 12 million girls are still as the result of infant mortality gains and high birth married as children annually,4 and in sub-Saharan rates. Their young age structures offer an unprecedented Africa, 35% of girls—versus 30% of boys—are not in opportunity for progress, which has stimulated global school.5 commitment to adolescents and, in particular, adoles- Girls at the highest risk of the worst outcomes—like cent girls. Although attention to adolescent girls in low- child marriage, early pregnancy, and HIV infection— often miss the benefits of social sector programs because a Poverty, Gender, and Youth Research Program, Population Council, New York. of their socially isolated and marginalized status. Girls Correspondence to Miriam Temin ([email protected]). who lack contact with schools, where youth programs

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often take place, also may be excluded from for- CBGG programs. We explored how programs with Girls at the mal health and financial services and labor CBGGs were designed and their effects. We also highest risk of the markets. Adolescent girls with access to health fa- identified questions that merit further research to worst health cilities rarely receive adolescent-friendly services; inform programming to empower girls and ad- outcomes often providers may overlook their specific health needs vance their well-being. By critically reviewing im- miss the benefits 6 or treat them insensitively. pact evaluation evidence on CBGGs in LMICs, we of social sector Some programs use community-based girl aimed to answer 4 questions: program because groups (CBGG) to address risk for girls who are 1. What design features do CBGGs with impact of social isolation hard to reach through formal delivery channels and like schools and health services. In CBGG pro- evaluations have? marginalization. grams, girls and young women meet regularly 2. What did those evaluations measure? with a leader (e.g., a mentor) who uses a variety 3. What were the program effects on girls? of pedagogical methods to address sexual and re- 4. What type of study designs generated which productive health (SRH), HIV prevention, life results? skills, economic and financial outcomes, and other topics. The literature on CBGG programs was sub- CBGGs are proliferating across geographic jected to rigorous selection, search, abstraction, regions. For example, under the Determined, and analysis methods to produce a holistic, in- Resilient, Empowered, AIDS-free, Mentored, and formed assessment of this program delivery model. Safe (DREAMS) Partnership to reduce HIV infec- tions among adolescent girls and young women, implementing partners in 14 countries in sub- Saharan Africa and Haiti use CBGGs to build ado- METHODS lescent girls’ and young women’s social and other Study Selection assets (e.g., cognitive, economic, health assets).7 We reviewed literature in search of evaluations of Often, these are called “safe space” programs be- programs that used group-based methods to deliv- cause they meet in community-based venues that er content to adolescent girls to build their life girls and parents perceive as safe and private, skills and empower them. To be considered for which can reduce barriers to attendance and en- our analysis, the program had to include: (1) a able discussion of sensitive issues. The Population group of 10- to 19-year-old girls who met regu- Council tests the CBGG model based on a theory larly (i.e., more than once); (2) a female mentor of change that posits when multisectoral programs who received dedicated training for the role; and (3) a meeting venue located in a community set- address girls holistically, content is tailored to re- ting rather than a formal institution (e.g., not hos- spond to heterogeneous girl segments, and group pitals or schools during formal classroom hours). meetings are accessible and mentor-led, they can We considered group leaders as “mentors” if they ’ build girls protective assets and empower them were at least slightly older than participants, con- to reduce risk and increase opportunity in the sistent with the majority of programs in our sam- 8 right environment. ple; peer educators also were considered if they fit Increasingly, randomized controlled trial (RCT) our criteria. evidence joins the body of quasi-experimental Programs underwent 2 levels of screening to studies of CBGG programs, expanding both the be included in our analysis. The first screening amount and type of evidence available. However, assessed if the evaluated program included the this evidence is not always available to funders elements described above. The second screening and implementers in an accessible form they can focused on the rigor of the evaluation methodol- use to inform decision making. One explanation is ogy. To clear this screening, study designs had to there has been little analysis of the evaluation evi- have: an impact evaluation that used an experi- dence specific to CBGG programs, although they mental or quasi-experimental study design, data – collected at a minimum of 2 time points, an inter- are included in broader reviews.9 11 The time is vention and control/comparison group, and quan- right to consolidate what is known about CBGGs titative program effects and probability values We conducted the to help donors, researchers, policy makers, and (P values). We also included descriptive publica- first-ever implementers make informed decisions regarding tions (i.e., those that did not report P values) if 12 funding, research, policy, and practice. they provided supporting information about pro- literature review To help fill the gap between evidence genera- grams that were described in other papers in our dedicated to tion and evidence use, we conducted the first- sample. Evaluations that constructed a post hoc CBGG program ever literature review focused on the evidence on comparison group using statistical methods, such evidence.

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as propensity score matching, did not pass this engagement activities); and evaluation details screening. (sample size, program effects). We limited our search to peer-reviewed and non-peer-reviewed (gray) literature in English Data Analysis and Synthesis published between 2000 and 2017. For reporting purposes, we created and defined ef- fect categories based on the description in the eva- Participants luations and the stated program goals. To enable In our review, we sought evaluations of programs the interpretation of the wide range of evaluation that targeted adolescent girls aged 10 to 19 years results, we constructed 8 outcome domains that who were married or unmarried. Programs with aggregated the range of effects evaluated. The out- young women (i.e., aged 20–24 years) were in- come domains are: (1) health beliefs and attitudes, cluded only if adolescent girls also were enrolled. (2) gender beliefs and attitudes, (3) education- For programs with older participants (i.e., aged related outcomes, (4) psychosocial outcomes, over 24 years), the analyses had to be stratified (5) health and gender knowledge and awareness by or controlled for age to pass our screening. (6 of 7 on health), (6) economic and financial out- Programs that included adolescent boys and comes, (7) health-related behavior, and (8) health young men also passed the screening if their ana- status. If evaluations used multiple indicators to lyses controlled for sex or disaggregated results. assess the same outcome, we combined them into 1 aggregated effect per study. For example, in the psychosocial outcome domain, social support is a Outcomes composite of numerous indicators: sociability, To understand the programs’ operations and re- number of friends, ability to go to girl/youth ported effects, we assessed both implementation groups, has at least 1 social safety net, social inclu- science and impact evaluation findings. The eval- sion index, and others (Table 1). uations used a large variety of impact measures Within each domain, we report beneficial— across programs that encompassed both proximal statistically significant (a=0.05) changes in the and distal effects on outcomes. Program evalua- intended direction (i.e., protective direction tions relied heavily on self-reported data, and a [null value] for advantageous out- (e.g., biomarker testing for HIV, herpes simplex vi- comes)—and null (nonsignificant) measures for rus 2 [HSV-2], pregnancy status; banking informa- each effect. We also assessed the total number of tion about savings amounts; problem sets to gauge times that evaluations measured effects in each numeracy and literacy levels). outcome domain across the programs. Analyzing effect sizes was beyond the scope of the review. Search Strategy We considered unintended effects as a statistically We searched for related publications and captured significant change in the detrimental direction but them based on a review of titles, abstracts, and excluded them from the analysis. summaries. To identify papers for our sample, we consulted systematic and other reviews of evi- dence on interventions for adolescents11,13–16 and Ethics 3ie’s evidence gap map on adolescent SRH.17 We Since this study did not involve human subjects also consulted research and journal databases research, we did not seek institutional review (e.g., Google Scholar, JSTOR, EBSCO’S Academic board approval. Search Complete, POPLINE, and DeepDyve) using key words including “girl-centered,”“safe spaces,” RESULTS and “mentor.” We also reviewed web sites of rele- vant implementing organizations with a history Literature Search Results of programming for adolescent girls in LMICs. The initial review produced 183 manuscripts, Programs outside LMICs were excluded. articles, and reports. The first screening eliminated 73 documents; we subjected the remaining Data Extraction 110 publications to the second screening and re- We extracted program details including: design fea- moved an additional 62 whose evaluation design tures (country, setting); program aims; descriptions did not meet our requirements. This left 48 publica- of participant details (girls’ characteristics, mentor tions that reported on evaluations of 30 programs: qualifications); group characteristics (group size, 14 RCTs and 16 using quasi-experimental design meeting frequency, program duration, topics (Figure 1). The program details and reported find- covered including health services and male ings for these programs are found in Table 2.Sixty

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TABLE 1. Community-Based Girl Group Program Effects by Outcome Domains

Reported Effect Measure(s): Beneficial Out of Totala

Health beliefs/attitudes Improved attitudes toward early pregnancy 2/2 Increased concerns about unprotected sex 2/2 Increased demand for health servicesb 2/2 Affected their perceived vulnerability to HIV/AIDS 1/1 Improved attitudes toward female genital mutilation/cutting 1/1 Improved attitudes toward family sizes 2/3 10/11 (90.9%) Gender beliefs/attitudes Changed perception of gender roles and norms 7/8 Improved attitudes towards child marriage 5/6 Improved attitudes towards gender-based violence 4/7 Improved beliefs regarding girls' education 1/2 Improved attitudes towards girls’ economic empowerment 1/2 18/25 (72.0%) Education-related outcomes Improved numeracy skills 4/4 Increased vocational training 1/1 Reduced need for tutoring 1/1 Increased school enrollment 3/4 Improved literacy skills 2/4 Increased school retention 1/3 Increased grade attainment 1/3 13/20 (65.0%) Psychosocial outcomes Increased self-efficacy regarding condom use 2/2 Increased self-efficacy to assert opinions and concerns 6/7 Increased social supportc 7/9 Increased self-efficacy to seek out HIV testing 1/1 Increased autonomy when searching for a job 2/3 Increased mobility 4/10 Improved self-esteem 1/3 Reduced experience of gender discrimination 0/1 23/36 (63.8%) Continued

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TABLE 1. Continued

Reported Effect Measure(s): Beneficial Out of Totala

Knowledge/awareness-health Increased HIV knowledge 9/12 Increased reproductive health knowledge 6/10 Increased STI knowledge 5/9 Increased menstrual regulation knowledge 1/2 Increased awareness of sexual and reproductive health and HIV 1/2 Knowledge/awareness-gender Increased awareness of marital-related rightsd 2/4 24/39 (61.5%) Economic and financial outcomes Increased household assets 1/1 Decreased food insecurity 1/1 Increased monthly expenditures 1/1 Increased number of savings accounts (formal and informal) 7/8 Increased employment 5/6 Increased earnings 2/4 Increased savings amount 1/4 Increased financial literacy 0/3 Reduced dowry practices 0/2 18/30 (60.0%) Health-related behavior Increased secondary abstinence 1/1 Increased menstrual hygiene management 1/1 Increased utilization of violence treatment, support, and/or prevention services 1/1 Increased health service utilization 3/6 Reduced child marriage 3/8 Increased condom use 5/11 Increased contraceptive use 3/9 Delayed sexual debut 2/6 Decreased transactional sex 1/3 Decreased number of sex partners 1/7 Reduced drugs or alcohol misuse 0/1 Increased HIV testing 0/2 21/56 (37.5%) Continued

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TABLE 1. Continued

Reported Effect Measure(s): Beneficial Out of Totala

Health status Improved self-rated health status 1/1 Decreased female genital mutilation/cutting 1/1 Decreased pregnanciese 2/5 Decreased experience of physical violence 1/3 Decreased experience of sexual violencef 2/7 Decreased HSV-2 incidence 1/4 Delayed pregnancy 0/1 Decreased negative mental health outcomes 0/2 Reduced STI symptoms 0/3 Decreased HIV incidence 0/4 8/31 (25.8%)

Abbreviations: HSV-2, herpes simplex virus 2; STI, sexually transmitted infection. a Denominator=total number of times each effect was measured across all the programs. Numerator=number of times a measured effect was statistically significant (i.e., beneficial). A program could not contribute to an effect’s denominator and numerator more than once. An aggregate total of the effect measures is presented at the bottom of each domain. b For example, contraceptives and voluntary counseling and testing. c Social support includes increasing girls’ support from elders (e.g., family and non-family adults whom girls can turn to in need) and peers (e.g., social safety nets, girls’ clubs, friends). d For example, detriments of child marriage and legal age of marriage. e This effect includes early, unintended, and current pregnancies. f Aggregates the measurement of indicators that described experiences of rape and indecent/unwanted touching by someone of the opposite sex, including a husband.

FIGURE 1. Results of Literature Search on Community-Based Girl Group Program Evaluations

Publications captured in program and literature search (N=183)

Literature screened by program Literature excluded components (N=183) (n=73)

Literature screened by study design Literature excluded (n=110) (n=62)

Literature included in review (n=48) 30 Programs

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TABLE 2. Details of Final Sample of Community-Based Girl Group Programs, N=30

Country and Program Name, Date Setting Program Design and Aims Participant Details Group Characteristics and Content Evaluation Details and Program Effectsa

The Bangladeshi Bangladesh, Randomized control trial Girls: Met weekly, 2–3 hours, 18 months’ Sample size: Association for Life Skills, rural Aims: 12–18 years old, in and out duration 7,452 intervention (2,516 education arm, Income, and Knowledge for Delay marriage among adolescent of school, unmarried Topics: 2,460 gender awareness arm, 2,476 Adolescents (BALIKA),18 girls by offering skills-building Mentors: Education arm: math and English tutoring livelihoods arm), 2,530 control/comparison 2013–2015 approaches aimed at empowering Local, young, slightly older than (in-school girls), computing or financial Effects: girls in 3 Bangladesh communities participants training (out-of-school girls) Increased health service utilization with highest child marriage rates: Gender-rights arm: Life skills training on Increased menstrual hygiene management Khulna, Satkhira, and Narail gender rights and negotiation, critical Reduced child marriage thinking, and decision making Improved numeracy skills Livelihoods skills training arm: Training in Increased school retention computers, entrepreneurship, mobile Increased school enrollment phone servicing, photography, and basic Reducedneedfortutoring first aid Increased social support All arms: Community engagement Increased employment activities, basic life skills, exposure to Increased HIV knowledge using computers and tablets Increased RH knowledge Increased STI knowledge Improved attitudes toward child marriage Improved attitudes toward GBV Reduced dowry payments Increased contraceptive use Increased mobility Reduced experience of gender discrimination Increased menstrual regulation knowledge Increased awareness of marital-related rights Changed perception of gender roles and norms

Empowerment and Bangladesh, Quasi-experimental Girls: 30 girls, met weekly, 2–3 hours Sample size: Livelihoods for Adolescents rural Aims: 10–24 years old, in and Topics: 322 intervention, 242 control/ (ELA): Bangladesh,19 Assess program’s usefulness in terms out of school, married and Health, life skills training, microfinance, comparison 2005–2007 of delaying age of marriage, keeping unmarried girls' rights, books, games Effects: girls enrolled in school, enhancing Mentors: Increased mobility sociability, and increasing mobility BRAC program supervisor Increased social support and awareness about health issues Increased earnings Increased savings amount Increased financial literacy

Growing Up Safe & Bangladesh, Randomized control trial Girls: 15 girls, 20 months’ duration Sample size: Healthy,20 2012–2013 urban Aims: 10–35 years old, in and out of Topics: 2,656 interventionb (1,910 female [15-19 Improve sexual and RH and rights, school, married (15–29-years Life skills training, legal rights/GBV, years old], 746 male [18–24 years reduce intimate-partner violence old) and unmarried (10–14 referrals to health or legal services old]),1287 control/comparisonb (952 among women and girls in urban years old) Also included: female [15–19 years old], 335 male slums, reduce child marriage Mentors: Boys/young men engagement [18–24 years old]) Observed leadership qualities, Effects: rapport with community, Decreased experience of physical violence willingness to work on Decreased experience of sexual violence campaign activities Reduced child marriage

Kishori Abhijan,21 Bangladesh, Quasi-experimental Girls: Group characteristics information was Sample size: 2001–2003 rural Aims: 10–19 years old, in and out of not specified 1,901 intervention, 310 control/ Promote a gender-equitable school, married and unmarried Topics: comparison environment where girls can broaden Mentors: Life skills training, legal rights, gender, Effects: their choices, participate in Employed at BRAC or Center for economic empowerment (savings Increased employment empowering social and economic Mass Education and Science, accounts, credit access) Reduced child marriage processes, and realize their potential demonstrated experience and Increased school retention as agents for social change capacity working with adolescent Reduced dowry practices girls Continued

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TABLE 2. Continued

Country and Program Name, Date Setting Program Design and Aims Participant Details Group Characteristics and Content Evaluation Details and Program Effectsa

– Ishraq,22 25 2001–2013 Egypt, Quasi-experimental Girls: 30 girls, met 4 days/week, 4 hours, pilot Sample size: rural Aims: 13–15 years old (pilot), 11–15 for 30 months, scale-up for 20 months Pilot: 453 intervention, 134 Create safe spaces where out-of- years old (scale-up), out of duration control/comparison school girls can learn, play, and school (both phases) Topics: Scale-up: 1,321 intervention, 539 build self-confidence, improve out- Mentors: Life skills training, sports, livelihoods control/comparison of-school girls' knowledge and Local, at least secondary school training, domestic skills, legal rights, IDs/ Effects: attitudes regarding transitions to education official documentation, financial Decreased female genital adulthood (e.g., early marriage, RH, education, nutrition mutilation/cuttingc and education) Also included: Improved numeracy skillsImproved Boys/young men engagement literacy skills Increased self-efficacy to assert opinions and concerns Increased RH knowledge Improved attitudes toward child marriage Improved attitudes toward family sizes Improved attitudes toward female genital mutilation/cutting Changed perception of gender roles and norms Increased health service utilization Increased mobility Improved self-esteem Improved attitudes toward GBV Improved beliefs regarding girls' education

Berhane Hewan,26 Ethiopia, Quasi-experimental Girls: 15–20 girls, unmarried girls met Sample size: 2004–2006 rural Aims: 10–19 years old, in and out of 5 days/week, married girls met weekly 650 interventionb, 736 control/ Improve educational attainment, RH school, married and unmarried Topics: comparisonb knowledge, contraceptive use, and Mentors: Nonformal education, livelihoods training, Effects: age at first marriage 10th grade education referrals to RH services Increased contraceptive use Reduced child marriage Increased school enrollment Increased HIV knowledge Increased awareness of sexual and RH and HIV/AIDS Increased STI knowledge Improved literacy skills Increased grade attainment

– Biruh Tesfa,27 29 Ethiopia, Quasi-experimental Girls: Met 5 days/week, 2 hours, 38 sessions Sample size: 2006–2016 urban Aims: 7–18 years old, out of school, Topics: Gondar: 767 intervention,b 405 control/ Increase social networks and support married and unmarried Life skills, HIV counseling and treatment, comparisonb to poorest, most marginalized girls in Mentors: financial literacy, vouchers for health care, Addis Ababa: 630 intervention, 646 poorest urban areas of Ethiopia; Adult women from the school materials control/comparison improve girls’ knowledge and skills to community Effects: prevent HIV Increased health service utilization Improved numeracy skills Improved literacy skills Increased school enrollment Increased social support Increased HIV knowledge Increased demand for health services Increased HIV testing Increased grade attainment Continued

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TABLE 2. Continued

Country and Program Name, Date Setting Program Design and Aims Participant Details Group Characteristics and Content Evaluation Details and Program Effectsa

Better Life Options,30 India, Quasi-experimental Girls: 15–20 girls, met almost daily, Sample size: 2006–2008 rural Aims: 13–17 years old, in and 2 hours, 6–9 months’ duration 810 intervention, 228 control Enhance girls' awareness of sexual out of school, unmarried Topics: Effects: and RH matters; build agency in Mentors: Life skills training, livelihoods, sports Increased mobility terms of mobility, decision making, Young, educated, articulate, Increased number of savings accounts and sense of self-worth; foster local, can manage big groups (formal & informal) egalitarian gender role attitudes; Increased HIV knowledge develop vocational skills and future Increased STI knowledge work aspirations; influence Increased awareness of marital-related perceptions about marriage and rights their ability to negotiate marriage- Improved attitudes toward child marriage related decisions and success in Changed perception of gender roles and delaying marriage and first norms pregnancy Reduced child marriage Increased self-efficacy to assert opinions and concerns Increased RH knowledge Increased awareness of sexual and RH and HIV

First-time Parents Project,31 India, Quasi-experimental Girls: 8–12 girls, met monthly, 2–3 Sample size: 2003–2004 rural Aims: Mean age 19.4 years old, in- hours Diamond Harbour: 403 Develop and test integrated package school status not reported, only Topics: intervention, 259 control of health and social interventions to years of schooling completed, Legal literacy, vocational training, Effects: improve married young women's married savings and credit management, Increased self-efficacy to assert opinions reproductive and sexual health Mentors: pregnancy, gender, spousal and concerns knowledge and practices, enhance Staff of Child In Need Institute relationships Increased social support their ability to act in their own or Deepak Charitable Trust Also included: Increased STI knowledge interest, and expand their social Access and quality improvements of Changed perception of gender roles and support networks health services norms Increased contraceptive use Increased mobility Improved attitudes toward GBV

Promoting Change in India, Quasi-experimental Girls: 30 girls, Sample size: Reproductive Behavior rural Aims: 15–24 years old, in and out of Phase 1 duration: Phase 3: 2,171 intervention (1,382 – in Bihar (PRACHAR),32 36 Change beliefs of people 12–24 school, married and unmarried 21 months (Patna) female, 789 male), 1,050 control/ 2001–2004 years old about RH/FP, challenge Mentors: 24 months (Nawada) comparison (679 female, 371 male) traditional behavior patterns of early Semi-literate, known and 27 months (Nalanda) Effects: childbearing and inadequate spacing respected by community Phase 2 duration: Not specified Increased contraceptive use between children, and promote members Phase 3 duration: 7 months Increased grade attainment informed and healthy reproductive Topics: Increased mobility behavior; change parents’ beliefs and Sexual and RH, nutrition, spousal Increased self-efficacy to assert opinions influential community adults about negotiation, gender norms and concerns RH/FP, provide knowledge to discour- Also included: Increased autonomy when searching for a age early marriage of daughters, curb Boys/young men engagement, access job pressure on young couples for early and quality improvements of health Increased number of savings accounts childbearing, and encourage services (formal & informal) adequate spacing of subsequent Increased HIV knowledge children; increase use of Increased RH knowledge contraceptives among young married Increased menstrual regulation knowledge couples, particularly to delay first child Increased awareness of marital-related until mother is mature, and to space rights subsequent births by at least 3–5 years Improved attitudes toward child marriage Improved attitudes toward early pregnancy Increased demand for health services Changed perceptions of gender roles and norms Reduced child marriage Delayed pregnancy Continued

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TABLE 2. Continued

Country and Program Name, Date Setting Program Design and Aims Participant Details Group Characteristics and Content Evaluation Details and Program Effectsa

Improving Learning Kenya, Quasi-experimental Girls: 230 after-school sessions, 34 life skills Sample size: Outcomes and Transition urban Aims: 12–19 years old, in school sessions 855 intervention, 416 control/comparison to Secondary School Promote access to and improve the Mentors: Topics: Effects: Study,37 2013–2015 quality of secondary education among 21–40 years old, completed Life skills training, homework support on Improved numeracy skills girls who live in informal urban secondary school numeracy and literacy Improved literacy skills settlements

Nyeri Youth Health Kenya, Quasi-experimental Girls: Met weekly, 90–120 minutes, 4–8 weeks’ Sample size: Project,38 1998–2000 urban and Aims: 10–24 years old, in and out of duration 2,504 interventionb (1,220 female, 1,284 rural Delay sexual debut among sexually school, unmarried Topics: male),905 controlb (472 female, 443 male) inexperienced youth, prevent Mentors: Life skills training Effects: negative sexual health outcomes Local, respected, well-known Decreased number of sex partners among sexually experienced youth, adults and young parents Increased secondary abstinence create RH information and service Increased self-efficacy to assert opinions and environment that was responsive to concerns information and service needs of Increased condom use young people Delayed sexual debut

Safe and Smart Savings,39 Kenya, Quasi-experimental Girls: 15–25 girls, met weekly, 30–90 minutes, Sample size: 2008–2010 urban Aims: 10–19 years old, in and out of 16 sessions 615 intervention, 284 control/comparison Develop, pilot test, and roll-out school, unmarried Topics: Effects: individual savings accounts to girls Mentors: Financial education, RH information Increased mobility belonging to girls' groups Young women from community Increased autonomy when job searching Program evaluation aims: Understand Increased social support the social, economic, and health Increased number of savings accounts (for- effects of participating in program mal and informal) activities Decreased experience of sexual violence

Tap and Reposition Kenya, Quasi-experimental Girls: 15–25 girls, met weekly, 1–2 hours, Sample size: Youth,40 2001–2004 urban Aims: 16–22 years old, out of school, 36 months’ duration 222 intervention, 222 control/comparison Reduce adolescents’ vulnerabilities to married and unmarried Topics: Effects: adverse social and RH outcomes by Mentors: Loan policies and procedures, business Increased earnings improving their livelihood options Must have worked in a advice, gender issues, team building, Increased number of savings accounts profession related to counseling, adolescent RH, life skills, HIV/AIDS (formal and informal) social work, business, health Increased household assets care, community development, Increased self-efficacy regarding condom or business use Increased HIV knowledge Increased condom use Increased savings amount Increased RH knowledge Increased STI knowledge Improved attitudes toward girls' economic empowerment Improved attitudes toward GBV

iCuídate! Promueve tu Mexico, Randomized control trial Girls: 6–8 girls, met weekly, 6 hours, 2 Sample size: Salud (Take Care of urban Aims: 13–17 years old, in school consecutive Saturdays 394 intervention,d 314control/comparisond Yourself! Promote Your Increase use of condoms and other Mentors: Topics: Effects: Health),41 2002–2004 contraceptives, decrease risky sexual Trained HIV/AIDS, health promotion, exercise, Increased condom use behaviors of Mexican youth nutrition, substance abuse Increased contraceptive use Also included: Delayed sexual debut Boys/young men engagement

Choices,42,43 2010 Nepal, Quasi-experimental Girls: Met weekly, 2 hours, 3 months’ duration Sample size: rural Aims: 10–14 years old, in school, Topic: 309 intervention (148 female, 161 male), Improve gender equity among very unmarried Gender norms 294 control/comparison (135 female, 159 young adolescents Mentors: Also included: male) 18–24 years old, graduate of Boys/young men engagement Effects: the clubs, community members Improved attitudes toward GBV Improved beliefs regarding girls' education Changed perception of gender roles and norms Continued

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TABLE 2. Continued

Country and Program Name, Date Setting Program Design and Aims Participant Details Group Characteristics and Content Evaluation Details and Program Effectsa

Networks of Hope,44 South Africa, Randomized control trial Girls: 14–17 years old; enrolled 18 girls, met weekly, 60–90 Sample size: 2012–2014 rural Aims: in OVC programming minutes, 13–16 weeks’ duration 785 intervention (375 female, 410 male), For psychological intervention, Mentors: Topics: 229 control/comparison (110 female, mitigate mental health problems; Trained lay adult (for Life skills training, group therapy 119 male) for behavioral intervention, build psychological intervention), Also included: Effects: participants' HIV knowledge and trained young adult from Boys/young men engagement, access Increased condom use related skills; Both interventions community (for behavioral and quality improvements of health Decreased number of sex partners were situated within broader OVC intervention) services Delayed sexual debut program offering educational and economic support to adolescents and their families

Siyakha Nentsha,45 South Africa, Quasi-experimental Girls: Met 2–3 days/week, 1 hour, 2 years’ Sample size: 2008–2012 rural Aims: Grade 10-11, in school duration 359 femalee, 356 malee Powered to detect increased number Mentors: Topics: Effects: of participants who save money and 20–24 years old, recent Life skills training, nutrition, rights, Increased social support knowledge of government social secondary school graduates, financial literacy, job readiness Increased number of savings accounts grants, decrease social exclusion, local Also included: (formal and informal) increase interaction with formal Boys/young men engagement Decreased number of sex partners financial institutions, improve HIV- prevention behaviors

Stepping Stones,46,47 South Africa, Randomized control trial Girls: 3 hours, 6–8 weeks’ duration Sample size: 2003–2006 rural Aims: 16–26 years old, in and out of Topics: 1,409 intervention (715 female, 694 Reduce incidence of HIV and HSV-2 school Life skills training,GBV, HIV counseling/ male), 1,367 control/comparison (701 and improve sexual practices among Mentors: treatment, comprehensive sex education female, 666 male) youth in South Africa's rural Eastern Same age or slightly older than Also included: Effects: Cape Province girls, had post-school Boys/young men engagement Decreased HSV-2 incidence qualification, open-minded and Decreased HIV incidence gender sensitive Decreased pregnancies Decreased experience of physical violence Decreased negative mental health outcomes Decreased experience of sexual violence Decreased transactional sex Increased condom use Decreased number of sex partners Reduced drugs or alcohol misuse

Adolescent Development Tanzania, Randomized control trial Girls: Met 5 days/week, 2 hours Sample size: 3,179f Program,48 2009–2011 urban and Aims: 14–20 years old, in and Topics: Effects: rural Improve human capital and out of school, married and Sexual and RH, Life skills training, Increased number of savings accounts financial market participation of unmarried livelihood training, microfinance/ (formal and informal) young women by providing Mentors: microcredit, laws and rights Changed perception of gender roles and vocational training and information Adolescent leader from same norms on sex, reproduction, and marriage community, few years older than Decreased pregnancies girls Reduced STI symptoms Decreased experience of sexual violence Increased condom use Delayed sexual debut Reduced child marriage Increased school retention Increased employment Increased earnings Increased savings amount Increased HIV knowledge Improved attitudes toward child marriage Improved attitudes toward family sizes Continued

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TABLE 2. Continued

Country and Program Name, Date Setting Program Design and Aims Participant Details Group Characteristics and Content Evaluation Details and Program Effectsa

Mabinti Tushike Tanzania, Quasi-experimental Girls: 10–15 girls, met 1–2 days/week, 32 Sample size: Hatamu!,49 2012–2015 urban and Aims: 10–19 years old, out of school, months’ duration 291 intervention, 357 control/comparison rural Reduce adolescent girls’ vulnerability married and unmarried Topics: Effects: to HIV, pregnancy, and violence Mentors: Life skills, income-generating activities, Increased condom use 19–23 years old, similar to GBV education, education Increased health service utilization participants, recruited by local Increased utilization of violence treatment, government or advertisement support, and/or prevention services Increased vocational training Increased self-efficacy to assert opinions and concerns Increased social support Increased employment Increased RH knowledge Decreased negative mental health outcomes Increased contraceptive use Decreased number of sex partners Delayed sexual debut Increased mobility Improved self-esteem Increased financial literacy

Young Citizens Program,50 Tanzania, Randomized control trial Girls: Met weekly, 2–3 hours, 28 weeks’ Sample size: 2004–2005 urban Aims: 9–14 years old, in and out duration 313 intervention,g 300 control/ Increase youth participants' competencies of school Topics: comparisong so that they can plan and implement Mentors: Social ecology, citizenship, community Effects: integrated health promotion activities Young adults, completed health, HIV/AIDS knowledge Increased self-efficacy to assert opinions that educate their communities and secondary school, previous Also included: and concerns encouragethemtotakeactiontoward experience in youth-related Boys/young men engagement HIV/AIDS prevention, testing, and treatment HIV activities

Empowerment and Uganda, Randomized control trial Girls: Met 5 days/week, 2 years’ Sample size: Livelihoods for urban and Aims: 14–20 years old, in and out of duration 3,964 intervention, 2,002 control/comparison Adolescents: Uganda,51 rural Bolster girls’ cognitive and school, married and unmarried Topics: Effects: 2008–2010 noncognitive skills with: vocational Mentors: Life skills training, sexual and RH, Decreased experience of sexual violence skills training to enable adolescent From community, slightly older vocational training, financial Decreased pregnancies girls to start small-scale income than target girl population literacy Increased condom use generating activities, life skills to Reduced child marriage build knowledge and reduce risky Increased employment behaviors Increased monthly expenditures Increased HIV knowledge Increased RH knowledge Improved attitudes toward child marriage Improved attitudes toward early pregnancy Improved attitudes toward family sizes Changed perception of gender roles and norms Reduced STI symptoms Increased contraceptive use Increased health service utilization Increased school enrollment Increased earnings

Safe and Smart Uganda, Quasi-experimental Girls: 15–25 girls, met weekly, 30–90 minutes, Sample size: Savings,39,52 urban Aims: 10–19 years old, in and out of 16 sessions 750 intervention, 312 control/comparison 2009–2011 Develop, pilot test, and roll-out school, unmarried Topics: Effects: individual savings accounts to girls Mentors: Financial education, RH information Increased number of savings accounts belonging to girls' groups 20–35 years old, reside in same (formal and informal) Program evaluation aims: community as girls in group, Increased HIV knowledge Understand the social, economic, interest in working with Improved attitudes toward GBV and health effects of participating in vulnerable adolescent girls Increased HIV testing program activities Increased mobility Increased autonomy when job searching Increased social support Decreased experience of sexual violence Continued

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TABLE 2. Continued

Country and Program Name, Date Setting Program Design and Aims Participant Details Group Characteristics and Content Evaluation Details and Program Effectsa

– Suubi Project,53 58 Uganda, Randomized control trial Girls: 7 girls maximum Sample size: 2005–2016 rural Aims: 11–17 years old, in school, Suubi: Monthly, 1–2 hours, 12 sessions Suubi: 135 intervention (82 female, 53 Suubi: Improve health, mental health, unmarried Suubi-Maka: Not specified male), and life chances of AIDS-orphaned Mentors: SuubiþBridges: Monthly, 1 hour, 9 months’ 142 control/comparison (75 female, 67 adolescents through microfinance and University students, tried to duration male) economic empowerment recruit graduates of program Topics: Suubi-Maka:179 intervention (117 Suubi-Maka: Improve orphaned Child savings accounts, financial literacy, female, 62 male), adolescents' attitudes toward HIV- asset building, life skills, HIV prevention 167 control/comparison (108 female, 59 preventive practices and future cash Also included: male) savings over time, as well as increase Boys/young men engagement SuubiþBridges: 913 intervention (398 their cash savings female, 515 male), SuubiþBridges: Develop ability to 497 control/comparison (228 female, identify future goals and educational 269 male) aspirations by building their self- Effects: esteem; Improve school attendance Improved self-rated health and grades, encourage hopefulness, Improved self-esteem enhance safe sex decision making, Increased savings amount and decrease sexual risk-taking Increased HIV knowledge behavior Affected their perceived vulnerability to HIV/AIDS Increased concerns about unprotected sex Improved attitudes toward girls' economic empowerment

Exploring the World of Vietnam, Randomized control trial Girls: 10 girls, met weekly for 2 hours, 10 Sample size: Adolescents,59 2006 urban and Aims: 15–20 years old, in and sessions 281 intervention (149 female,132 male), rural Increase knowledge about HIV, STIs, out of school, unmarried Topic: 317 control/comparison (167 female, and pregnancy and contraceptives; Mentors: Life skills training 150 male) improve perceptions related to Trained, from the community Also included: Effects: condom use and abstinence; Boys/young men engagement, access Increased HIV knowledge increase condom use response and quality improvements of health Increased RH knowledge efficacy; decrease intention to engage services Increased STI knowledge in sex in the next 3 months

Focus on Kids,59,60 Vietnam, Randomized control trial Girls: 10 girls, met weekly, 2 hours, 10 sessions Sample size: 2001–2003 urban and Aims: 15–20 years old, in and Topic: 317 intervention (167 female, 150 male), rural Increase knowledge about HIV, STIs, out of school, unmarried Life skills training 281 control/comparison (149 female, and pregnancy and contraceptives; Mentors: Also included: 132 male) improve perceptions related to Trained, from the community Boys/young men engagement, access Effects: condom use and abstinence; increase and quality improvements of health Increased HIV knowledge condom use response efficacy; services Increased RH knowledge decrease intention to engage in sex in Increased STI knowledge the next 3 months

Adolescent Girls' Zambia, Randomized control trial Girls: 20–30 girls, met weekly, 1–2 hours, 3 Sample size: Empowerment urban and Aims: 10–19 years old, in and years’ duration 3,104 intervention (1,043 safe space Program,61,62 rural Empower adolescent girls by instilling out of school, unmarried Topics: arm, 1,031 safe spaceþhealth voucher 2013–2016 them with social, health, and economic Mentors: Life skills training, savings account, health arm, 1,030 safe spaceþhealth assets that they can draw upon to 20–40 years old, completed vouchers voucherþsavings account arm), reduce vulnerabilities and expand grade 12, can speak and write Also included: 1530 control/comparison opportunities, thereby increasing their in English, experienced Access and quality improvements of health Effects: likelihood of completing school and services Decreased transactional sex delaying sexual debut and reducing Increased condom use the risks of early marriage, unintended Delayed sexual debut pregnancy, and HIV acquisition Increased STI knowledge Improved attitudes toward GBV Decreased HIV incidence Decreased HSV-2 incidence Increased mobility Increased number of savings accounts (formal and informal) Increased financial literacy Continued

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TABLE 2. Continued

Country and Program Name, Date Setting Program Design and Aims Participant Details Group Characteristics and Content Evaluation Details and Program Effectsa

Regai Dzive Shiri Zimbabwe, Randomized control trial Girls: 20–30 girls, 4 weeks’ duration Sample size: Project,63,64 rural Aims: 18–22 years old, in and Topics: 2,319 intervention (1,241 female, 1,078 2003–2007 Reduce incidence of HIV and HSV-2 out of school, married and HIV prevention, self-awareness and male),1,353 control/comparison (1,352 and rates of unintended pregnancy, unmarried communication, rural development (risk female, 1,001 male) improve knowledge, attitudes, and Mentors: and body mapping, drama, Effects: behaviors related to gender issues, School leaver in the year between storytelling, and role play) Decreased pregnancies HIV, and sexual risk leaving school and starting Also included: Increased self-efficacy regarding condom university Boys/young men engagement, access use and quality improvements of health Increased self-efficacy to seek out HIV services testing Increased RH knowledge Increased STI knowledge Increased concerns about unprotected sex Decreased HIV incidence Decreased HSV-2 incidence Reduced STI symptoms Increased condom use Increased contraceptive use Increased health service utilization Decreased number of sex partners Increased awareness of marital-related rights

Shaping the Health of Zimbabwe, Randomized control trial Girls: 25 girls, 4–6 weeks’ duration, Sample size: Adolescents in Zimbabwe urban Aims: 16–19 years old, out of school, additional 6 months duration for 158 intervention, 157 control/comparison (SHAZ!) Project,65 Improve sexual and structural risk married and unmarried livelihoods component Effects: 2006–2008 factors and decrease unintended Mentors: Topics: Increased employment pregnancy and HIV and HSV-2 Self-selected adults Life skills training, livelihoods, microgrants Decreased food insecurity incidence among adolescent female Also included: Decreased HIV incidence orphans Access and quality improvements of health Decreased HSV-2 incidence services Decreased pregnancies Decreased experience of physical violence Decreased experience of sexual violence Increased condom use Increased contraceptive use Decreased transactional sex Decreased number of sex partners Increased social support

Abbreviations: FP, family planning; GBV, gender-based violence; HSV-2, herpes simplex virus 2; RH, reproductive health; STIs, sexually transmitted infections. a Italicized effects signify statistical significance [a=0.05]). b Evaluation used cross-sectional surveys to collect baseline and end line data; although, the methodology report didn’t contain details on matching or follow-up. Based on the assumption that baseline and end line samples covered different people, we aggregated the number of respondents across both in the calculation. c Though female genital mutilation/cutting (FGM/C) significantly increased for participants in control group compared to intervention arm, the study cites differing FGM traditions may be the reason, e.g., ages villages traditionally perform FGM/C. Difference between baseline and end line prevalence show most girls (>50%) in program villages entered program already circumcised, while most girls in control villages (<40%) were not. This suggests control villages perform FGM/C at later ages than program villages and the statistically significant difference-in-difference calculation between program and control villages might not be attributable to intervention. d Evaluation reports more female than male participants (405 versus 303) but doesn’t report numbers of females/males in each arm. e Evaluation provides sex-stratified demographic information/analyses; doesn’t report numbers of females/males in each arm. f Total sample size for both intervention and control/comparison arm; evaluation doesn’t specify numbers for each. g Evaluation controls for sex in multivariable models but doesn’t report numbers of females/males in each arm.

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percent of programs took place in Africa (Eastern: needed to assess exposure; however, less than half 40%, Southern: 20%), and one-third occurred in the programs reported this. According to that South/Southeast Asia. information, programs retained an average of 75% of participants (definitions of retention varied Implementation Science Findings from 50% to 100% of sessions). Program design and the quality of implementation The information provided about coverage influences program effects. The replication of a revealed that the largest number of programs tar- program with proven efficacy may fail to have the geted unmarried girls aged 13–18 years who were same real-world effect if not implemented with fi- both in school and not in school; more programs delity to the original design. Despite this, research occurred in rural than in urban areas (14 rural, on design features is largely missing from the liter- 9 urban, 7 in both; Figure 3). The limited details 10 ature. We sought to fill this gap by collecting in- about which girls the programs tried to reach formation on selected design features of programs made it difficult to determine if they targeted girls in our sample. To note, not every publication pro- at highest risk of the outcomes they sought to ad- vided the same amount of program design, plan- dress. For example, for HIV prevention, were the ning, and implementation details. In addition, girls who learned about condom self-efficacy the information was insufficient to compare the attri- butes of individual programs in our sample and same girls having unprotected sex with an older rigorously assess success factors. partner? For child marriage prevention, were the The amount of information on design features girls who learned about the risks of early marriage varied considerably. Of 30 programs, 16 reported the girls most likely to be married off? on the size and 21 on the frequency of group Around one-third of programs reported that meetings (Figure 2). The most common group they adapted aspects of program design to differ- size was 15 to 25 girls, who typically met in groups ent girl segments. Underscoring the importance weekly for 1 to 3 hours. Although no clear pattern of recognizing adolescent girls’ heterogeneity, par- emerged on program lifespan, nearly half of those ticipation and program effects varied between reporting this information operated for more than types of girl. The subset of evaluations that disag- a year. Information on girls’ actual participation is gregated participation rates by girl segment (e.g.,

FIGURE 2. Frequency of Selected Design Features of Community-Based Girl Group Programs

12

10

8

6

4 No. of programs No. of (N=30)

2

0 < 10 10 to 14 15 to 25 26 to 30 weekly < weekly > weekly 60-90 2-3 hours > 3 hours < 4 4-12 Over 1 minutes months months year Group size (n=16) Meeting frequency (n=21) Session duration (n=16) Program duration (n=23)

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FIGURE 3. Frequency of Participants’ Features in Community-Based Girl Group Programs

18 16

14

12

10

8

6

No. of programs No. of (N=30) 4

2

0 both both both rural urban married 13 to 18 13 to 22 16 to 19 10 10 to 15 10 in school in unmarried out of school of out Age (n=30) Location (n=30) Schooling (n=28) Marital status (n=24)

by age [10–14 years, 15–19 years], schooling and complement the girl-centered content and pro- marital status) found that younger girls attended mote an enabling environment, program staff more frequently than older girls and unmarried used varied tactics to engage community mem- girls attended more frequently than married girls, bers, local leaders, families, and male partners. whose responsibilities and social expectations dif- Programs recruited female mentors who fer. The variation in participation points to the im- often were local to the program community. portance of disaggregating design features and Although most mentors were lay people, 4 pro- evaluation results for programs that target large, grams recruited professionals from relevant fields, diverse groups of girls—for instance, girls aged such as teachers and program staff. A schooling 10 to 19 years, or both girls in school and not in qualification was common, primarily secondary school—which characterized around half the pro- school graduation or the local equivalent. The grams in the sample. mentors received specific training for their role; CBGG programs used a variety of interven- among those reporting this information, mentor training lasted 5 days or longer, and a few pro- tions to deliver content to girls (Figure 4). In grams conducted refresher training following the addition to serving as a base for referrals and initial mentor training. Despite the central role of community engagement, enhancements may mentors in this program model, reports rarely in- have influenced outcomes for girls. All but 4 pro- cluded details like selection criteria, job descrip- grams included content on life skills. Only tions, and training strategies. 2 of the 30 programs restricted themselves to a sin- gle content area; in 17 programs, mentors com- Program Effects bined life skills training with activities related to Distribution of Program Effects by Outcome economic and financial outcomes, like income Domain generation skills, financial literacy training, and Assessment of Evidence Base. Table 1 presents access to microsavings or cash transfers. Nearly the total number of times that evaluations mea- one-third of programs included activities to sured the effects in each outcome domain across strengthen access to and/or quality of health ser- programs. Figure 5 shows the amount of evidence vices, such as health vouchers. Programs also in- available for each domain and the number of cluded recreational activities such as sports and times those outcomes were measured; a program games. Across different content areas, regular contributes 1 “time reported” (i.e., the y-axis) per group meetings built social support with mentors effect (e.g., increased mobility). Evaluations mea- and peers to reduce social isolation. To sured multiple outcomes and, therefore, could

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FIGURE 4. Types of Girl-Centered Content in Safe-Space Style Programsa

30

25

20

15

10 No. of programs No. of (N=30) 5

0

aNearly all programs addressed multiple content areas.

FIGURE 5. Distribution of Community-Based Girl Group Program Effects by Outcome Domaina,b

60

50 Quasi null effect measures RCT null effect measures Quasi beneficial effect measures 40 RCT beneficial effect measures

30

20 Times reported

10

0 Health-related Health and gender Psychosocial Health status Economic and Gender beliefs and Education- Health beliefs and behavior knowledge/ outcomes financial attitudes related attitudes awareness outcomes outcomes

Abbreviations: Quasi, quasi-experimental; RCT, randomized controlled trial. aBeneficial = Reported statistically significant (a=0.05). bNull = Reported non-significant (a=0.05).

be counted more than once per domain. For ex- knowledge and awareness on health and gender, ample, an evaluation could contribute 2 times then psychosocial outcomes and health status. reported to the psychosocial outcomes domain if Figure 5 also shows the reported beneficial and its evaluation measured both mobility and social null effect measures. In absolute terms, evalua- support. Health-related behavior was the most tions reported the largest number of beneficial frequently measured domain, followed by measures for knowledge and awareness on health

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and gender, followed by psychosocial outcomes, their knowledge and attitudes to promote healthy then health-related behavior, economic and fi- and safe transitions to adulthood, reported that nancial outcomes, gender beliefs and attitudes, it improved girls’ attitudes toward performing education-related outcomes, health beliefs and female genital mutilation/cutting on their daugh- attitudes, and health status. ters in the future.22 Regai Dzive Shiri was a cluster The number of beneficial effect measures in RCT to reduce HIV among Zimbabwean youth each outcome domain is not strictly comparable who were in school and not in school through because the quantity of reported measures varied work with community members, clinic staff, and between domains. For example, programs had young people. Its evaluation reported that it in- more opportunity to display changes in health- creased girls’ concerns about unprotected sex related behaviors than education-related out- (Table 2).63,64 comes because more reported on the former than the latter. To avoid biased interpretation, it is more Gender Attitudes and Beliefs informative to compare the number of beneficial Programs aimed to shift participants’ beliefs measures with the overall number of measures and attitudes toward a more egalitarian stance by (beneficialþnull) within each domain. In relative addressing practices like child marriage and terms, programs reported more (i.e., >50%) ben- gender-based violence (GBV). Twelve programs eficial measures than null ones for beliefs and atti- aspired to change girls’ attitudes and beliefs re- tudes about health and gender, education-related garding gender; collectively, 72% of this domain’s outcomes, psychosocial outcomes, knowledge and effect measures were beneficial (Table 1). awareness on health and gender, and economic Program evaluations reported improvements and financial outcomes. Programs reported fewer in girls’ attitudes or perceptions toward GBV, child (<50%) beneficial measures for health-related marriage, and gender roles and norms. For exam- behaviors and health status. Results for each do- ple, an evaluation of Choices, a curriculum-based main are detailed below in order of the proportion program to shift gender-related attitudes and of beneficial effect measures, from most to least behaviors in rural Nepal, reported that the pro- relative benefits. gram reduced girls’ acceptance of GBV.42 An eval- Review of Evaluations and Their Effects. uation of Better Life Options, a life skills education Figure 5 differentiates effects by study design. It program in Uttar Pradesh, India, reported that it indicates the likelihood that results are generaliz- improved girls’ attitudes toward child marriage able given that results of RCTs are more robust (Table 2).30 than other designs, although all impact evalua- tions in the sample met our criteria for rigor (as Education-Related Outcomes described above). To note, most effects on health Programs aimed to improve education-related status, health-related behavior, and knowledge behaviors (e.g., school enrollment) and skills and awareness were measured in RCTs, and quasi- (e.g., numeracy). Evaluations of 10 programs experimental studies focused heavily on psycho- assessed education-related effects and reported social outcomes. Across all outcome domains, beneficial effects 65% of the time they were mea- quasi-experimental studies reported more benefi- sured (Table 1). cial measures than RCTs. Overall, program evaluations reported improve- ments in girls’ numeracy skills and increases in Program Effects by Outcome Domain school enrollment. In Ethiopia, Biruh Tesfa worked Health Attitudes and Beliefs with marginalized girls to improve education- Programs focused on topics that threaten girls’ related outcomes. Among participants with no for- growth and development, such as early pregnancy mal schooling, the evaluation reported that the pro- 27 and female genital mutilation/cutting, to shift gram increased girls’ numeracy and literacy scores. their attitudes about their health. Seven programs An evaluation of the scale-up of Ishraq reported that sought to change girls’ health beliefs and attitudes; girls’ reading comprehension and multiplication 23 in total, 91% of the effect measures reported a sig- skills improved (Table 2). nificant change in the intended direction, making this the domain with the highest proportion of Psychosocial Outcomes beneficial measures (Table 1). Evaluations used a variety of indicators to track psy- The evaluation of Ishraq, a program in Upper chosocial outcomes, which include self-efficacy, Egypt to empower adolescent girls and improve mobility, autonomy, and social support, as well as

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experience of gender discrimination. Evaluations Economic and Financial Outcomes of 19 programs reported psychosocial outcomes, Evaluations of 15 programs measured economic and 64% of these effect measures were statistically and financial outcomes and reported beneficial significant. Proportionally, more than half of the measures 60% of the time. The effects with the measures of girls’ self-efficacy regarding SRH highest proportion of beneficial measures were in- behaviors, such as condom use and HIV testing, creasing girls’ employment, savings accounts, and social support, and assertiveness were beneficial household assets, as well as decreasing food inse- (Table 1). curity. The results related to girls’ earnings were The evaluation of BRAC’s Employment mixed (i.e., 50% beneficial), and according to the and Livelihood for Adolescents program—which evaluations, no program reduced dowry practices aimed to reduce child marriage, keep girls in (Table 1). school, and increase girls’ peer socialization in The evaluation of the Shaping the Health of Bangladesh through income generation and Adolescents in Zimbabwe (known as SHAZ!) group activities—reported that it increased girls’ Project, which aimed to prevent HIV among ado- mobility.19 The Young Citizens Program in lescent girls through structural interventions, Tanzania used education and community mobili- reported that it increased girls’ receipt of their zation to strengthen very young adolescents’ own income.65 Siyakha Nentsha was a 2-armed in- agency in planning and implementing health pro- tervention in South Africa to improve girls’ and motion activities related to HIV. The evaluation boys’ economic well-being that provided training reported that it increased girls’ efficacy to assert on life skills, HIV/STI prevention, and social capi- their thoughts and opinions with peers and tal building. One arm also received household fi- 50 adults. Also in Tanzania, the evaluation of nancial management and small business planning Mabinti Tushike Hatamu!, a program to reduce the (financial education arm) and another received vulnerability of girls who were not in school, training in sexuality, reproductive rights, and reported that it increased the number of girls who stress and violence reduction (stress management said that community leader requested their opin- arm). The evaluation reported that Siyakha 49 ion (Table 2). Nentsha increased the number of savings accounts (stress management arm) and girls’ interaction with banks (financial education arm) (Table 2).45

Knowledge and Awareness about Health and Health-Related Behavior Gender Nineteen programs sought to improve behaviors, Seventeen programs aspired to improve girls’ especially those related to SRH (e.g., transactional knowledge about health topics, like HIV and mar- sex, condom use). Collectively, 38% of the effect riage-related rights. Their evaluations reported measures reported for this domain were benefi- beneficial effect measures 62% of the time, with cial. Effects that were beneficial every time they more success on knowledge measures related to health (63%) than to gender (50%). Evaluations were measured included: increased secondary ab- reported more beneficial effects regarding HIV and stinence; menstrual hygiene management; and reproductive health knowledge than regarding sex- violence treatment, support, and/or prevention ually transmitted infection (STI) and menstrual services. One-third of the programs included com- regulation knowledge and awareness of marriage- plementary activities to improve access to and qual- related rights (Table 1). ity of health services; however, evaluations An evaluation of the Suubi & Bridges Project, a reported that health service utilization significantly Ugandan peer mentorship program to protect AIDS- increased only 50% of the time it was measured. orphaned adolescents against HIV and STIs by Child marriage significantly decreased nearly providing culturally appropriate HIV information, 40% of the times it was measured according to reported that the program increased HIV knowl- evaluation reports. Most program evaluations edge.53 In India, Promoting Change in Reproductive reported null effects for girls’ number of sex part- Behavior (known as PRACHAR) in Bihar aimed to ners, transactional sex, condom use, sexual debut, increase contraceptive use and delay pregnancy. and contraceptive use (Table 1). Although it reportedly increased reproductive health Although well under half of this domain’s knowledge, it did not succeed in delaying first preg- measures were beneficial (38%), individual pro- nancy (Table 2).32 grams reported notable changes in health

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behavior. The Bangladeshi Association for Life measured, which may or may not encompass all Skills, Income, and Knowledge for Adolescents the changes resulting from the programs. For (known as BALIKA) program aimed to reduce these reasons, the relative assessment, which indi- child marriage using weekly girl-only meetings cates how the program did in relation to its aims, is combined with different topics across 3 study more informative than the absolute assessment. arms. The program’s evaluation reported that it de- Different types of study designs in our sample creased the odds of child marriage across all 3 arms: yielded different types of results. In general, the girls in the tutoring arm had the lowest odds of RCTs emphasized outcomes that could be objec- marriage before the age of 18.18 The evaluation of tively measured in the domains of health status Networks of Hope, a multi-arm South African pro- and behavior (albeit mostly self-reported). The gram to reduce HIV risk by improving psychological quasi-experimental evaluations tended to empha- and behavioral outcomes, reported that it increased size outcomes that are more complex to measure, such as psychosocial outcomes and attitudes. girls’ consistent condom use.44 In a rare example of Evaluations of programs using CBGGs reported a longitudinal effect measure, the evaluation of a improvements in girls’ attitudes and beliefs about Mexican program, Cuídate! Promueve tu Salud, gender and health; boosts in educated-related out- reported that it increased participants’ age at first 41 comes, such as numeracy and school enrollment; sex in a 4-year follow-up survey (Table 2). and increases in girls’ economic and psychosocial assets. They also reported positive effects on knowl- Health Status edge and awareness about health and gender. In Evaluations of 11 programs (8 were RCTs) assessed general, these results suggest that CBGGs appear changes in health status using self-reports and bio- to have more potential to impact individual out- markers. Few evaluations reported statistically sig- comes than outcomes that rely on a group. nificant improvements in health status effects, such Theoretically, all of these are along the causal path- as experience of physical violence and HSV-2 inci- way to good health. dence; of the times evaluations measured im- Despite the reported boost that programs gave proved health status, only 26% were beneficial. mediating factors that theoretically improve The 4 programs that measured HIV incidence did health behavior and health status, reports of pro- not report a decrease. Evaluations reported that gram performance on behavior and health status measures of decreasing girls’ experience of sexual is mixed. For instance, condom use increased less and physical violence were null more often than than half the times measured (5 of 11) and contra- beneficial. No programs reported mental health ceptive use increased one-third of the times mea- improvements or STI reductions (Table 1). sured (3 of 9). Only one-quarter of reported Stepping Stones is a program to improve sexu- measures of girls’ health status (e.g., experience al health with participatory learning to build of physical or sexual violence, fertility, STI inci- knowledge, risk awareness, and communication dence) were statistically significant, and child skills. Its evaluation reported that the program marriage practices improved just under half the reduced HSV-2 incidence.46 The evaluation of time that evaluations measured them (3 of Growing Up Safe & Healthy in Bangladesh, which 8 times). These results are not unexpected given used a multipronged delivery model including that attitudes and knowledge change faster than 66 male groups, female groups, and community mo- behavior and, ultimately, health status. bilization, reported it decreased girls’ experience The theoretical pathway to health behavior of physical and/or sexual violence (Table 2).20 change is well-documented and offers possible reasons that changes in mediating factors did not consistently translate into behavior change and DISCUSSION better health within evaluation time frames. The main CBGG The expanding evidence base on CBGGs enables Explanations relate to girls’ locus of control and program benefits 67,68 an analysis of their effects across programs and program and study designs. First, the main to girls appear to countries. Notably, the size of the evidence base benefits of CBGG programs reflect changes that be internal — varies for each outcome domain and limits compa- are internal to girls for example, attitudes to- changes, such as rability between the summaries of impact. The ward child marriage, demand for health services, attitudes toward variation reflects funding patterns for CBGGs, self-esteem, and literacy. In general, effects are child marriage which are dominated by HIV prevention, explain- weaker on outcomes that rely on factors external and self-esteem. ing the preponderance of health behavior mea- to girls—such as condom use, HIV testing, child surement. The results only describe what was marriage, and health service utilization. This

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difference may reflect inequitable interpersonal behavioral risk within evaluation time frames. relationships; weak access to transport, finances, This would limit the likelihood of evaluations services; and other socioeconomic factors that finding sexual behavioral and health effects. impede girls’ ability to exercise their voice, choice, Long-term follow-up would reveal if benefits en- and control over behaviors and, consequently, dure and these girls reduce behavioral and health their health and well-being. Notably, most pro- risks as they age or if benefits wash out over time. grams with CBGGs included activities to engage community members that theoretically have the Limitations potential to reduce barriers to behavior change. The summary of CBGGs effects is informative. However, details on community engagement However, limited evidence and the lack of compa- and its influence on girl-level outcomes was rability between studies make these results pre- rarely reported in the impact evaluations in our liminary. The small size of the evidence base, as sample. well as the tremendous variability in the study Second, related to study and program design, designs, implementation features, and outcomes participation rates varied between different sub- measured, prevented us from conducting a meta- populations of girls. This may have led to mixed analysis, which would have enabled us to assess effects for different girl segments that reported effects across programs. More evidence, including results may have masked. For instance, if younger from implementation science research, would girls participate more in meetings than older girls, shed light on the most promising design features, they may derive more benefits that may not ap- making the practical implications of impact evalua- pear in a summary effect measure.61 Zambia’s tion results clearer. In addition, too few multicom- Adolescent Girls’ Empowerment Program docu- ponent studies compared different combinations of mented more participation among younger and interventions and content to enable a detailed as- rural participants than older and urban ones; not sessment of attribution. For example, we could not surprisingly, the evaluation found that younger assess the effect of group-level changes resulting unmarried girls benefited more than older mar- from community engagement activities that may ried girls. 61 Given their central role in delivering have influenced girl-level effects. content in CBGGs, mentor performance is another Although the literature review was compre- important mediator of effects masked by aggregat- hensive, it was not a systematic review; as a result, ed results. The scant evidence available on mentor we may have missed relevant evidence. The ten- quality indicates that mentors’ own characteristics dency to favor positive results in publications and the quality of their performance is a major may have led us to overestimate the benefits of source of variability in girls’ participation and im- CBGGs. Additionally, evaluations relied heavily pact. 61 Aggregated results of impact evaluations of on self-reported information, which introduces programs for diverse groups of girls (e.g., girls aged the possibility of social-desirability and recall 10–19 years in school and not in school) and men- biases. Finally, although the RCTs were designed tors risk eclipsing effects for some subsets of parti- to reduce the risk of selection bias, it is possible cipants in the absence of disaggregation. that girls who joined CBGG programs and partici- Third, related to study design, when and what pated regularly differed from nonparticipants and outcomes the impact evaluations measured influ- dropouts in ways that influenced the likelihood of enced our results. The types of outcome measures impact. that dominated impact evaluations and the data collection instruments used may not have been SUMMARY AND IMPLICATIONS FOR adequate to capture the types of changes that CBGGs are most likely to bring about. In addition, PROGRAMS, POLICIES, AND most evaluations captured short-term effects after RESEARCH programs ended; they rarely returned to measure Most CBGGs in our sample included 20 (6 5) girls, long-term impact. A few notable exceptions in- met weekly for more than an hour, and lasted for a clude Mexico’s Cuídate! Promueve tu Salud, where year or longer; they frequently combined life skills researchers returned 4 years after activities ended training with content to promote economic and fi- to assess the durability of effects. Most young ado- nancial outcomes, such as financial literacy or ac- lescents are not yet sexually active; given the pos- cess to microfunds/bank accounts. Providing girls sibility that younger participants attend more with an opportunity to build social connections regularly than older ones, it is conceivable that with peers and mentors in a safe space has intrinsic the most active CBGG participants faced the least value. Furthermore, the evaluations in this review

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indicate that programs with these characteristics vary between different girl segments, and which girl can use locally recruited female mentors to build segments are the most important to target (e.g., un- girls’ economic and psychosocial assets; improve married, younger girls) for broad changes over time their attitudes, beliefs, knowledge, and awareness and into the next generation? This program delivery on health and gender; and enhance education- model has salience for married girls, who often are related outcomes. Enhancements found in many socially isolated and facing high risk, but few impact programs like community engagement and health evaluations included them. Other questions on the services strengthening may have influenced the effects of CBGGs include how durable effects are impact of the CBGGs on girls. and if they wash out over time. These results suggest that CBGGs have more Given increased investment in CBGGs, evi- potential for benefits that may contribute to girls’ dence is needed on their scalability, such as the empowerment than to their health in the near minimum package of elements required to have term. Girls’ empowerment, which encompasses an effect. Evaluations of layered combinations of their voice, choice, and control over key aspects interventions would be informative. Other ques- of their lives, can increase their likelihood of grow- tions on designing for scale relate to the optimal 69,70 ing into successful, healthy adults. Empower- design model in real-world conditions: the ideal ment is a critical development goal in itself that dosage or level of exposure; duration; group size can position girls to make decisions and affect out- and composition; mentor qualifications and skills; comes of importance to themselves, their families, and the cost of retaining quality, effectiveness, and — and their communities especially when the so- cost-effectiveness as coverage expands. For an en- cial environment supports these changes. Beyond abling environment, how can girl programs effec- direct benefits, a girl’s empowerment can affect tively engage and mobilize boys, men, and other other aspects of her health and well-being. As girls community members? What are effective tactics gain voice, choice, and control, in the context of for institutionalizing CBGGs within existing gov- an enabling environment, over time they may ernment systems, including health systems, for benefit from improved outcomes, including sustainability? delayed marriage and pregnancy, reduced vio- Community-based programming can offer a lence, better health, more education, and greater way to reach adolescents who are out of school, dis- learning. Ultimately, these positive shifts may im- engaged from formal labor markets, and who rarely prove girls’ and women’s well-being and life use health services. Given that excluded adolescents chances and reduce the intergenerational trans- often face the highest risks of the worst outcomes, mission of poverty. assessing the potential of targeted CBGG programs These results have implications for research. to reach these subpopulations is vital to understand As the evidence on CBGGs grows, future studies their potential for equity and cost-effectiveness. should assess the types of girl-level changes More impact evaluations should disaggregate results CBGG programming is most likely to bring about, to reflect adolescent heterogeneity, as well as deter- including neglected outcomes such as mental mining what add-ons are required to reach and re- health and nutrition. More evidence would enable tain the most excluded girls. a rigorous comparison—such as a meta-analysis— of how this program model performs on key Acknowledgments: We thank Annabel Erulkar, Alejandra Colom, Karen Austrian, and Paul Hewett for their invaluable contributions to this outcomes, like child marriage, relative to other report. We are grateful for the substantive inputs from Nicole Haberland interventions, which would make an important and Katherine McCarthy based on the RISING (Research Initiative for Questions remain contribution to the evidence base. Ensuring im- Success in Girl programs) Review. Our gratitude also goes to the many researchers from the Population Council and elsewhere whose work we about how to use pact evaluations are robust and illuminate pro- reviewed in our evidence scan, and finally, to the many girls who CBGG platforms to gram methodology and outcome measurement participated in the programs described here and benefited in ways that even the impact evaluations did not capture. best protect and is paramount; using comprehensive research reporting standards and guidelines can help.71,72 empower Competing interests: None declared. Future evaluations also should consider using tri- adolescent girls in angulation techniques (i.e., comparing self- their communities. reported information to records) or supplemental REFERENCES data collection methods (e.g., direct observation) 1. The World Factbook 2020: Country Comparison: Median Age. to validate self-reported responses. Central Intelligence Agency website. 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Peer Reviewed

Received: December 5, 2019; Accepted: May 13, 2020

Cite this article as: Temin M, Heck CJ. Close to home: evidence on the impact of community-based girl groups. Glob Health Sci Pract. 2020;8(2):300- 324. https://doi.org/10.9745/GHSP-D-20-00015

© Temin and Heck. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https:// doi.org/10.9745/GHSP-D-20-00015

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